TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 25: Wound Care and Irrigation Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse assesses several preoperative patients for potential postoperative referrals to the
wound care team. Which patient assessment does the nurse use to identify the patient who is least likely to have delayed postoperative wound healing? a. Eight weeks postpartum from live vaginal birth in for tubal ligation b. Older than 70 years, coronary artery disease, and hypertension c. Six-week course of radiation therapy for a cancerous tumor d. Chronic obstructive lung disease on long-term prednisone therapy ANS: A
The patient with the lowest risk of delayed wound healing is the patient scheduled for a tubal ligation because she is likely to be 40 years old or younger, decreasing the risk for chronic disease. She is likely to have generally good health as evidenced by a live vaginal birth. The older patient with coronary artery disease and hypertension has atherosclerotic lesions in the heart aggravated by high blood pressure. The patient is likely to have atherosclerotic lesions in other vessels because atherosclerosis is a nonselective disease; thus the patient is at risk for delayed healing because of the potential for impaired tissue perfusion. Radiation therapy increases the risk of postradiation scarring and fibrosis which increases the risk of delayed healing. The patient taking prednisone is at high risk for delayed healing because glucocorticoids suppress inflammation and the immune system. DIF: Cognitive Level: Analyzing N TOP: Nursing Process: Assessment
OBJ: NCLEX: Physiological Integrity
2. The nurse assesses a patient with a surgical incision. What is an expected patient outcome on
the fourth postoperative day? a. The temperature is 103.1° F (39.5° C) at 8 AM and noon. b. The incision is slightly reddened and swollen without drainage. c. The skin is spongy and warm around the incision. d. The patient’s pain has been increasing gradually. ANS: B
By the fourth postoperative day the patient’s surgical incision is expected to have slight redness and swelling but no drainage, indicating a physiological, expected, inflammatory response to tissue injury. A temperature of 39.5° C is febrile and warrants further investigation to rule out infection. Spongy, warm skin around the wound area can indicate infection and requires follow-up. Increasing pain can indicate that the wound status is deteriorating and needs to be assessed. DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment
OBJ: NCLEX: Physiological Integrity
3. The nurse prepares to assess the patient’s wound after removing the dressing. Which does the
nurse implement to promote infection control? a. Scrubs the drain insertion site in a back-and-forth manner. b. Cleans the incision from wound edges toward the center.
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