Chapter 11: Inflammation and Wound Healing

Multiple Choice

1. Question: The nurse assesses a patients surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate?
2. Question: A patient with an open leg wound has a white blood cell (WBC) count of 13, 500/L and a band count of 11%. What action should the nurse take first?
3. Question: A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next?
4. Question: A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8 F (38.7 C). Which action by the nurse is most appropriate?
5. Question: A patients 4 3-cm leg wound has a 0.4 cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound?
6. Question: A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How would the nurse document this wound?
7. Question: A patient with rheumatoid arthritis has been taking corticosteroids for 11 months. Which nursing action is

most likely to detect early signs of infection in this patient?

1. Question: The nurse should plan to use a wet-to-dry dressing for which patient?
2. Question: A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer?
3. Question: A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage, what instructions are most important for the nurse to teach the mother?
4. Question: The nurse will perform which action when doing a wet-to-dry dressing change on a patients stage III sacral pressure ulcer?
5. Question: A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care?
6. Question: A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is most appropriate?
7. Question: When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing?
8. Question: After receiving a change-of-shift report, which patient should the nurse assess first?
9. Question: nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)?
10. Question: The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider?
11. Question: A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurses highest priority?
12. Question: Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative pressure wound therapy?
13. Question: After the home health nurse teaches a patients family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed?