Exam 14: Inflammation and Wound Healing

The nurse is caring for a client with diabetes who had abdominal surgery one week ago, and obtains the following data. Which of these findings should be reported immediately to the health care provider?

Which of the following nursing actions is most likely to detect early signs of infection in a client who is taking immuno-suppressive medications?

The charge nurse observes a new graduate performing a dressing change on a client with a stage 2 left heel pressure injury. Which of the following actions by the new graduate indicates a need for further education about pressure injury care?

Aclient is admitted to the hospital with a pressure injury on the left buttock. The nurse notes that the base of the wound is yellow and involves subcutaneous tissue. Which of the following pressure injury wound stages should the nurse document?

The nurse is assessing a client the morning of the first postoperative day and notes redness and warmth around the incision. Which of the following actions should the nurse implement?

The nurse is caring for an adult client with stage 3 pressure injuries on both heels who has been in hospital for 6 days. Which of the following timeframes for wound assessment is accurate when a client is in the acute care setting?

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

The nurse is caring for a client with a systemic bacterial infection that has "goose pimples," feels cold, and has a shaking chill. At this stage of the febrile response, which of the following assessments should the nurse monitor?

The nurse is planning care for a client and is preparing to complete a wet-to-dry dressing. Which of the following wound descriptions is appropriate for using this type of dressing?

During wound healing, a wound is resistant to infection during which of the following phases?

Aclient who has an infected abdominal wound develops a temperature of 40°C (104°F). All the following interventions are included in the client's plan of care. In which order should the nurse perform the following actions?

A client's temperature has been 38.8°C (101.8°F) for several days. The client's normal caloric intake to meet nutritional needs is 2 000 calories per day. Knowing that the metabolic rate increases 13% for every 1°C (33.8°F) increase in temperature above 37.8°C (100°F) in body temperature, calculate the total calories the client should receive each day.

The nurse is caring for a young adult client who is receiving antibiotics for an infected leg wound and has a temperature of 38.8°C (101.8°F). Which of the following actions by the nurse is most appropriate?

The nurse is caring for a client with diabetes who has been admitted for a laparotomy and possible release of adhesions. When planning interventions to promote wound healing, which of the following actions is priority?

Which nursing action will be included when the nurse is doing a wet-to-dry dressing change for a client who has a stage III sacral pressure injury?

A client who is confined to bed and who has a stage 2 pressure injury is being cared for in the home by family members. To prevent further tissue damage, which of the following actions should the nurse instruct the family members that it is most important?

The nurse is caring for a client who has an open surgical wound on the abdomen that contains a creamy exudate and small areas of deep pink granulation tissue. Which of the following terms should the nurse use to document these findings?

Aclient's 6 * 3 cm leg wound has a 2 mm black area surrounded by yellow-green semiliquid material. Which of the following dressings should the nurse use for wound care?

A client arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which of the following actions by the nurse is most appropriate?

Aclient with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. Which of the following actions is priority as a result of this assessment data?