Exam 13: Inflammation and Wound Healing

When caring for a patient after an abdominal surgery, the nurse will be most concerned about monitoring for wound dehiscence during which period?

A patient with an open abdominal wound has a complete blood cell (CBC) count and white blood cell (WBC) differential, which indicates a shift to the left. The nurse will anticipate that the next collaborative intervention will be to

The charge nurse observes a new graduate performing a dressing change on a stage III sacral pressure ulcer. Which action by the new graduate indicates a need for further education about pressure ulcer care?

The nurse assesses a surgical patient the morning of the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate?

The nurse will plan to use wet-to-dry dressings when providing care for a

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

The nurse is preparing to perform a wet-to-dry dressing change for a patient with infected leg burns. Which action is appropriate for this type of dressing change?

The nurse has just received change-of-shift report about the following four patients. Which patient will the nurse assess first?

A patient with massive trauma to the leg has a 7 cm by 10 cm full-thickness leg wound with extensive skeletal muscle damage and wide, irregular wound edges. The nurse will teach the patient that

A patient is admitted to the hospital with an infected pressure ulcer on the left buttock. The pressure ulcer is 5 cm long by 2.5 cm wide and is 1.5 cm deep. The base of the wound is yellow and involves subcutaneous tissue. The nurse classifies the pressure ulcer as stage

A chronically ill, bedfast patient cared for in the home by family members has a stage II pressure ulcer over the coccyx. To prevent further tissue damage, the home care nurse instructs the family members that it is most important to

A 76-year-old patient has a large open, infected surgical wound on the abdomen that contains a creamy exudate and small areas of deep pink granulation tissue. The nurse will document the wound as a

When admitting a patient with a stage III pressure ulcers on both heels, which information obtained by the nurse is of most concern?

A patient with a systemic bacterial infection has "goose pimples," feels cold, and has a shaking chill. At this stage of the febrile response, the nurse would expect to find

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 will the nurse perform the following actions?

A 24-year-old patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F. Which action by the nurse is most appropriate?

The nurse is admitting a diabetic patient who is scheduled for a laparotomy and possible release of adhesions. When planning interventions to promote wound healing, the nurse will be most concerned about

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, calculate the total calories the patient should receive each day.

A patient's 6 * f. 3-cm leg wound has a 2-mm black area surrounded by yellow-green semiliquid material. Which dressing will the nurse anticipate using for wound care?