NSG 211 Exam 1 Unit 2 – Inflammation
Questions And Answers (Guaranteed A+)
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. Notify the health care provider.
c. Document the assessment.
d. Assess the wound every 2 hours. - answer✔ANS: C
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.
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✔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.
ALL RIGHTS RESERVED.
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. Rising body temperature
b. Muscle cramps
d. Decreasing blood pressure - answer✔ANS: B
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.
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. - answer✔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.
A patient with rheumatoid arthritis has been taking oral corticosteroids for 2years. 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. - answer✔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 or anti-inflammatory medications such as corticosteroids.
A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which
action by the nurse is appropriate?
a. Elevate the ankle above heart level.
b. Apply a warm moist pack to the ankle.
c. Ask the patient to try bearing weight on the ankle.
d. Assess the ankle's passive range of motion (ROM). - answer✔ANS: A
Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE). Elevation of the
ankle will decrease tissue swelling. Moving the ankle through the ROM will increase swelling
and risk further injury. Cold packs should be applied the first 24 hours to reduce swelling. The
nurse should not ask the patient to move or bear weight on the swollen ankle because
immobilization of the inflamed or injured area promotes healing by decreasing metabolic needs
of the tissues.
A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain.
When planning interventions to promote wound healing, what is the nurse's highest priority?
a. Maintaining the patient's blood glucose within a normal range
b. Ensuring that the patient has an adequate dietary protein intake
c. Giving antipyretics to keep the temperature less than 102° F (38.9° C)
d. Redressing the surgical incision with a dry, sterile dressing twice daily - answer✔ANS: A
Elevated blood glucose will increase inflammation and have an impact on multiple factors
involved in wound healing. Ensuring adequate nutrition is also important for the postoperative
patient, but a higher priority is blood glucose control. A temperature of 102° F will not impact
adversely on wound healing, although the nurse may administer antipyretics if the patient is
uncomfortable. Application of a dry, sterile dressing daily may be ordered, but frequent
dressing changes for a wound healing by primary intention is not necessary to promote wound
healing.
A patient who has an infected abdominal wound develops a temperature of 104°F (40° C). All
the following interventions are included in the patient's plan of care. In which order should the
nurse perform the following actions? (Put a comma and a space between each answer choice
3|Page
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Fyndlay. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $12.49. You're not tied to anything after your purchase.
