Inflammation and Wound Healing
The number of the question corresponds to the same-numbered
outcome at the beginning of the chapter.
1. A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5°F temperature, slight erythema at the incision
margins, and 30 mL serosanguineous drainage in the Jackson-Pratt
drain. Based on this assessment, what conclusion would the nurse
a. The abdominal incision shows signs of an infection.
b. The patient is having a normal inflammatory response.
c. The abdominal incision shows signs of impending dehiscence.
d. The patient’s physician needs to be notified about her condition.
2. The nurse assessing a patient with a chronic leg wound finds local
signs of erythema and pain at the wound site. What would the nurse
anticipate being ordered to assess the patient’s systemic response?
a. Serum protein analysis
b. WBC count and differential
c. Punch biopsy of center of wound
d. Culture and sensitivity of the wound
3. A patient in the unit has a 103.7°F temperature. Which intervention would be most effective in restoring normal body temperature?
a. Use a cooling blanket while the patient is febrile.
b. Administer antipyretics on an around-the-clock schedule.
c. Provide increased fluids and have the UAP give sponge baths.
d. Give prescribed antibiotics and provide warm blankets for
4. A nurse is caring for a patient who has a pressure ulcer that is
treated with debridement, irrigations, and moist gauze dressings.
How should the nurse anticipate healing to occur?
a. Tertiary intention
b. Secondary intention
c. Regeneration of cells
d. Remodeling of tissues
5. A nurse is caring for a patient with diabetes who is scheduled for
amputation of his necrotic left great toe. The patient’s WBC count
is 15.0 × 106
/µL, and he has coolness of the lower extremities,
weighs 75 lb more than his ideal body weight, and smokes two
packs of cigarettes per day. Which priority nursing diagnosis
addresses the primary factor affecting the patient’s ability to heal?
a. Imbalanced nutrition: more than body requirements related to
b. Impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking
c. Ineffective peripheral tissue perfusion related to narrowed blood
vessels secondary to diabetes and smoking
d. Ineffective individual coping related to indifference and denial
of the long-term effects of diabetes and smoking
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