Medical Surgical Nursing Assessment and Management of Clinical Problems,10th Edition by Sharon L. Lewis – Test Bank

MULTIPLE CHOICE

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. c. Notify the health care provider.
b. Document the assessment. 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.

DIF: Cognitive Level: Apply (application) REF: 165
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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.

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.

DIF: Cognitive Level: Analyze (analysis) REF: 161
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity

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 c. Rising body temperature
b. Muscle cramps d. Decreasing blood pressure

ANS: C
The patient’s complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is 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.

DIF: Cognitive Level: Apply (application) REF: 164
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

4. A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C) The patient reports having no 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 (Tylenol) prescribed PRN for pain.

ANS: C
Mild to moderate temperature elevations (<103° F) do not harm young adult patients and may benefit host defense mechanisms. The nurse should continue to monitor the temperature. Antipyretics are not indicated unless the patient is complaining of 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 or to use a cooling blanket for a moderate temperature elevation.

DIF: Cognitive Level: Apply (application) REF: 164
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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 c. Hydrocolloid dressing
b. Nonadherent 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.

DIF: Cognitive Level: Apply (application) REF: 169
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

6. 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 c. Maceration
b. Slough 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.

DIF: Cognitive Level: Understand (comprehension) REF: 166
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

7. 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.
c. Measure the temperature every 2 hours.
d. Ask about feelings of fatigue or malaise.

ANS: D
The earliest manifestation of an infection may be “just not feeling well.” Common clinical manifestations of inflammation and infection are frequently not present when patients receive immunosuppressive medications.

DIF: Cognitive Level: Analyze (analysis) REF: 164
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

8. The nurse should plan to use a wet-to-dry dressing for which patient?
a. A patient who has a pressure ulcer with pink granulation tissue
b. A patient who has a surgical incision with pink, approximated edges
c. A patient who has a full-thickness burn filled with dry, black material
d. A patient who has a wound with purulent drainage and dry brown areas

ANS: D
Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue.

DIF: Cognitive Level: Apply (application) REF: 170
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

9. A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure ulcer?
a. Stage I c. Stage III
b. Stage II d. Stage IV

ANS: C
A stage III pressure ulcer has full-thickness skin damage and extends into the subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable damage such as redness or a boggy feel. Stage II pressure ulcers have partial-thickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.

DIF: Cognitive Level: Understand (comprehension) REF: 173
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

10. A young male patient with paraplegia has a stage II sacral pressure ulcer and is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family?
a. Change the patient’s bedding frequently.
b. Apply a hydrocolloid dressing over the ulcer.
c. Change the patient’s position every 1 to 2 hours.
d. Record the size and appearance of the ulcer weekly.

ANS: C
The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other interventions may also be included in family teaching.

DIF: Cognitive Level: Analyze (analysis) REF: 174
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity