Exam 11: Inflammation and Wound Healing

A patient's 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?

A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure ulcer?

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?

A young male patient with paraplegia has a stage II sacral pressure ulcer and is being cared for at home by his family. To prevent further tissue damage,what instructions are most important for the nurse to teach the patient and family?

A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C)The patient reports having no discomfort. Which action by the nurse is appropriate?

The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic?

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate?

A patient's temperature has been 101° F (38.3° C)for several days. The patient's normal caloric intake to meet nutritional needs is 2000 calories per day. Knowing that the metabolic rate increases 7% for each Fahrenheit degree above 100° in body temperature,how many total calories should the patient receive each day?

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate?

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?

The nurse should plan to use a wet-to-dry dressing for which patient?

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next?

A patient with an open leg lesion has a white blood cell (WBC)count of 13,500/µL and a band count of 11%. What prescribed action should the nurse take first?

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?

A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions? (Put a comma and a space between each answer choice [A,B,C,D]).

After receiving a change-of-shift report,which patient should the nurse assess first?

The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)?

After the home health nurse teaches a patient's family member about how to care for a sacral pressure ulcer,which finding indicates that additional teaching is needed?

A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient?

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?