Inflammation & Healing

Question 1

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.

Answer 1

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.

Question 2

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.

Answer 2

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.

WBC: 4.5-10
Band Count: immature WBC <10% is a normal band count

Question 3

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

Answer 3

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.

Question 4

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.

Answer 4

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.

Question 5

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

Answer 5

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.