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. Obtain wound cultures.
b. Document the assessment.
c. Notify the health care provider.
d. Assess the wound every 2 hours.
ANS: B
The incisional redness and warmth are indicators of the normal
initial (inflammatory) stage of wound healing by primary
intention. The nurse should document the wound appearance
and continue to monitor the wound. Notification of the health
care provider, assessment every 2 hours, and obtaining wound
cultures are not indicated because the healing is progressing
normally.
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?
a. Obtain cultures of the wound.
b. Begin antibiotic administration.
c. Continue to monitor the wound for drainage.
,d. Redress the wound with wet-to-dry dressings.
ANS: A
The increase in WBC count with the increased bands (shift to
the left) indicates that the patient probably has a bacterial
infection, and the nurse should obtain wound cultures. Antibiotic
therapy and/or dressing changes may be started, but cultures
should be done first. The nurse will continue to monitor the
wound, but additional actions are needed as well.
A patient with a systemic bacterial infection feels cold and has a
shaking chill. Which assessment finding will the nurse
expect next?
a. Skin flushing
b. Muscle cramps
c. Rising body temperature
d. Decreasing blood pressure
ANS: C
The patient's report of feeling cold and shivering indicate that
the hypothalamic set point for temperature has increased and the
temperature will be increasing. Because associated peripheral
vasoconstriction and sympathetic nervous system stimulation
will occur, skin flushing and hypotension are not expected.
Muscle cramps are not expected with chills and shivering or
with a rising temperature.
,A young adult patient receiving antibiotics for an infected leg
wound has a temperature of 101.8° F (38.7° C). The patient
denies any discomfort. Which action by the nurse is appropriate?
a. Apply a cooling blanket.
b. Notify the health care provider.
c. Check the patient's temperature again in 4 hours.
d. Give acetaminophen prescribed as-needed for pain.
ANS: C
Mild to moderate temperature elevations (less than 103° F) do
not harm young adult patients and may benefit host defense
mechanisms. Continue to monitor the temperature. Antipyretics
are not indicated unless the patient has fever-related symptoms,
and the patient does not require analgesics if not reporting
discomfort. There is no need to notify the patient's health care
provider of a fever in a patient who is already being treated for
the infection or to use a cooling blanket for a moderate
temperature elevation.
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. Dry gauze dressing
b. Nonadherent dressing
c. Hydrocolloid dressing
d. Transparent film dressing
ANS: C
The wound requires debridement of the necrotic areas and
, absorption of the yellow-green slough. A hydrocolloid dressing,
such as DuoDerm, would accomplish these goals. Transparent
film dressings are used for clean wounds or approximated
surgical incisions. Dry dressings will not debride the necrotic
areas. Nonadherent dressings will not absorb wound drainage or
debride the wound.
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. Eschar
b. Slough
c. Maceration
d. Undermining
ANS: D
Undermining is evident when a cotton-tipped applicator is
placed in the wound and there is a narrower "lip" around the
wound, which widens as the wound deepens. Eschar is a crusted
cover over a wound. Slough and maceration refer to loosening
friable tissue.
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?
a. Monitor white blood cell counts.
b. Check the skin for areas of redness.
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