ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 14 Questions
Question 1 of 5
The nurse is assessing a patient the morning of the first postoperative day and notes redness and warmth around the incision. Which of the following actions should the nurse implement?
Correct Answer: B
Rationale: 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 of 5
A patient with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. Which of the following actions is a priority as a result of this assessment data?
Correct Answer: A
Rationale: The shift to the left indicates that the patient probably has a bacterial infection, and the nurse will plan to 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.
Question 3 of 5
The nurse is caring for a patient with a systemic bacterial infection who has 'goose pimples,' feels cold, and rigors. At this stage of the febrile response, which of the following assessments should the nurse monitor?
Correct Answer: C
Rationale: 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 rising temperatures.
Question 4 of 5
Which of the following nursing actions is most likely to detect early signs of infection in a patient who is taking immuno-suppressive medications?
Correct Answer: D
Rationale: Common clinical manifestations of inflammation and infection are frequently not present when patients receive immuno-suppressive medications. The earliest manifestation of an infection may be 'just not feeling well'.
Question 5 of 5
The nurse is planning care for a patient and is preparing to complete a wet-to-dry dressing. Which of the following wound descriptions is appropriate for using this type of dressing?
Correct Answer: D
Rationale: 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.