ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 33 : Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse has 10 minutes before having to leave the room and administer blood to another patient. Which intervention is the priority for Sam?
Correct Answer: D
Rationale: Hanging the prescribed antibiotic is the priority intervention given the diagnosed osteomyelitis, a serious bone infection requiring prompt treatment to prevent further complications. This takes precedence over emotional support, family updates, or wound care consultation within the 10-minute timeframe.
Question 2 of 5
What interventions are most likely to be effective in engaging Sam in their treatment and prevention plan? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Engaging Sam involves active participation (
A), specialist interaction with reinforcement (
B), involving the partner for support (
C), and using a pressure-relief surface to prevent further wounds (
D). Teaching about the call bell and remote (E) is less relevant to wound care engagement.
Question 3 of 5
How will the nurse and Sam know that the treatment plan has been effective? Select all that apply.
Correct Answer: A,C,D
Rationale: Effective treatment is indicated by wound healing (
A), patient satisfaction and adherence (
C), and partner's ability to recognize infection signs (
D). Occasional fever (
B) suggests persistent infection, and walking a mile (E) is unrelated to wound healing outcomes.
Question 4 of 5
Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise as well as pain with redness at the surgical site. Which action is most appropriate?
Correct Answer: A
Rationale: The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.
Question 5 of 5
A nurse on a surgical unit has assessed and documented a patient's wound and drainage. Which statements most accurately describe the characteristic of the wound drainage?
Correct Answer: B
Rationale: Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serous drainage, generally watery, is composed primarily of the clear, serous portion of the blood and serous membranes. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. It is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.