Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank
Chapter 11: Inflammation and Healing
Harding: Lewis’s Medical-Surgical Nursing, 11th Edition
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.
b. Document the assessment.
c. Notify the health care provider.
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)
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.
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c. Continue to monitor the wound
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)
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
b. Muscle cramps
c. Rising body temperature
d. Decreasing blood pressure
ANS: C
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Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank
The patient’s report of feeling cold and shivering indicate that the hypothalamic set point for
temperature has increased and the temperature will be 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)
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
4. A young adult patient receiving antibiotics for an infected leg wound has a temperature of
101.8° F (38.7° C). The patient denies any 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 prescribed as-needed for pain.
ANS: C
Mild to moderate temperature elevations (less than 103° F) do not harm young adult patients
and may benefit host defense mechanisms. Continue to monitor the temperature. Antipyretics
are not indicated unless the patient has 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 of a fever in a patient who is already being treated for the infection or to use a
cooling blanket for a moderate temperature elevation.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
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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
b. Nonadherent dressing
c. Hydrocolloid 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)
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
b. Slough
c. Maceration
d. Undermining
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Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank
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)
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)
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 injury 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.
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d. A patient who has a woundUwith
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)
OBJ: Special Questions: Multiple Patients
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
9. A patient from a long-term care facility is admitted to the hospital with a sacral pressure
injury. The base of the wound involves subcutaneous tissue. How should the nurse classify
this pressure injury?
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4
ANS: C
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Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank
A stage 3 pressure injury has full-thickness skin damage and extends into the subcutaneous
tissue. A stage 1 pressure injury has intact skin with some observable damage such as redness
or a boggy feel. Stage 2 pressure injuries have partial-thickness skin loss. Stage 4 pressure
injuries have full-thickness damage with tissue necrosis, extensive damage, or damage to
bone, muscle, or supporting tissues.
DIF: Cognitive Level: Understand (comprehension)
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
10. A young male patient with paraplegia who has a stage 2 sacral pressure injury 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 injury.
c. Change the patient’s position every 1 to 2 hours.
d. Record the size and appearance of the injury 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)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
11. The nurse will perform which action for a wet-to-dry dressing change on a patient’s stage 3
sacral pressure injury?
a. Pour sterile saline onto the new dry dressings after packing the wound.
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b. Administer a prescribed PRN
minutes before the change.
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c. Apply antimicrobial ointment before repacking the wound with moist dressings.
d. Soak the old dressings with sterile saline 30 minutes before the dressing change.
ANS: B
Mechanical debridement with wet-to-dry dressings is painful, and patients should receive pain
medications before the dressing change begins. The new dressings are moistened with saline
before being applied to the wound but not soaked after packing. Soaking the old dressings
before removing them will eliminate the wound debridement that is the purpose of this type of
dressing. Application of antimicrobial ointments is not indicated for a wet-to-dry dressing.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
12. A new nurse performs a dressing change on a patient’s stage 2 left heel pressure injury. Which
action by the new nurse indicates a need for further teaching about pressure injury care?
a. The new nurse cleans the injury with half-strength peroxide.
b. The new nurse applies a hydrocolloid dressing on the injury.
c. The new nurse irrigates the pressure injury with saline using a 30-mL syringe.
d. The new nurse inserts a sterile cotton-tipped applicator into the pressure injury.
ANS: A
Pressure injuries should not be cleaned with solutions that are cytotoxic, such as hydrogen
peroxide. The other actions by the new nurse are appropriate.
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Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank
DIF: Cognitive Level: Apply (application)
TOP:
MSC: NCLEX: Safe and Effective Care Environment
Nursing Process: Evaluation
13. 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).
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.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
14. When admitting a patient with stage 3 pressure injuries on both heels, which information
obtained by the nurse will have the most impact on wound healing?
a. The patient has had the injuries for 6 months.
b. The patient takes oral hypoglycemic agents daily.
c. The patient states that the injuries are very painful.
d. The patient has several incisions that formed keloids.
ANS: B
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The use of oral hypoglycemics indicates diabetes, which can interfere with wound healing.
The persistence of the injuries over the past 6 months is a concern, but changes in care may be
effective in promoting healing. Keloids are not disabling, although the cosmetic effects may
be distressing for some patients. Actions to reduce the patient’s pain will be implemented, but
pain does not directly affect wound healing.
DIF: Cognitive Level: Analyze (analysis)
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
15. After receiving a change-of-shift report, which patient should the nurse assess first?
a. The patient who has multiple leg wounds with eschar to be debrided.
b. The patient receiving chemotherapy who has a temperature of 102° F.
c. The patient who requires analgesics before a scheduled dressing change.
d. The newly admitted patient with a stage 4 pressure injury on the coccyx.
ANS: B
Chemotherapy is an immunosuppressant. Even a low fever in an immunosuppressed patient is
a sign of serious infection and should be treated immediately with cultures and rapid initiation
of antibiotic therapy. The nurse should assess the other patients as soon as possible after
assessing and implementing appropriate care for the immunosuppressed patient.
DIF: Cognitive Level: Analyze (analysis)
OBJ: Special Questions: Multiple Patients
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Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
16. The nurse could delegate care of which patient to a licensed practical/vocational nurse
(LPN/VN)?
a. The patient who was just admitted after suturing of a full-thickness arm wound.
b. The patient who just reported increased tenderness and swelling in a leg wound.
c. The patient who requires teaching about home care for an open draining abdominal
wound.
d. The patient who needs a hydrocolloid dressing change for a stage 3 sacral pressure
injury.
ANS: D
LPN/VN education and scope of practice include sterile dressing changes for stable patients.
Initial wound assessments, patient teaching, and evaluation for possible poor wound healing
or infection should be done by the registered nurse (RN).
DIF: Cognitive Level: Apply (application)
OBJ: Special Questions: Delegation
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
17. The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which
finding is most important for the nurse to report to the health care provider?
a. Blood glucose of 136 mg/dL
b. Separation of proximal wound edges
c. Oral temperature of 101° F (38.3° C)
d. Patient reports increased incisional pain
ANS: B
N R I G B.C M
U S N T
O possible wound dehiscence and should be
Wound separation 3 days postoperatively
indicates
immediately reported to the health care provider. The other findings will also be reported but
do not require intervention by the HCP as rapidly.
DIF: Cognitive Level: Analyze (analysis)
OBJ: Special Questions: Prioritization
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
18. A patient who has diabetes and acute abdominal pain is admitted for an exploratory
laparotomy. When planning postoperative 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
ANS: A
Elevated blood glucose will impair wound healing in multiple ways. Ensuring adequate
nutrition is important for the postoperative patient, but a higher priority is blood glucose
control. A temperature of 102° F will not impact wound healing. 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.
DIF: Cognitive Level: Analyze (analysis)
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Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
19. Which finding is most important for the nurse to communicate to the health care provider
when caring for a patient who is receiving negative-pressure wound therapy?
a. Low serum albumin level
b. Serosanguineous drainage
c. Deep red and moist wound bed
d. Cobblestone wound appearance
ANS: A
Serum protein levels may decrease with negative pressure therapy, which will adversely affect
wound healing. The other findings are expected with wound healing.
DIF: Cognitive Level: Analyze (analysis)
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
20. After the home health nurse teaches a patient’s family member about how to care for a sacral
pressure injury, which finding indicates that additional teaching is needed?
a. The family member uses a lift sheet to reposition the patient.
b. The family member uses clean tap water to clean the wound.
c. The family member dries the wound using a hair dryer on a low setting.
d. The family member places contaminated dressings in a plastic grocery bag.
ANS: C
Pressure injuries need to be moist to facilitate wound healing. The other actions indicate a
good understanding of pressure ulcer care. The use of lift sheets prevents shearing forces.
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contaminated dressings prevents
of infection.
DIF: Cognitive Level: Apply (application)
MSC: NCLEX: Physiological Integrity
TOP:
Nursing Process: Evaluation
SHORT ANSWER
1. A patient’s temperature has been 101° F (38.3° C) for several days. The patient’s normal
caloric intake to meet nutritional needs is 2000 calories perday. If the metabolic rate increases
7% for each Fahrenheit degree above 100° in body temperature, how many total calories
should the patient receive each day?
ANS:
2140 calories
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
OTHER
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Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank
1. 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 [A, B, C, D]).
a. Administer IV antibiotics.
b. Sponge patient with cool water.
c. Perform wet-to-dry dressing change.
d. Administer acetaminophen (Tylenol).
ANS:
A, D, B, C
The first action should be to administer the antibiotic because treating the infection that has
caused the fever is the most important aspect of fever management. The next priority is to
lower the high fever, so the nurse should administer acetaminophen to lower the temperature
set point. A cool sponge bath should be done after the acetaminophen is given to lower the
temperature further. The wet-to-dry dressing change will not have an immediate impact on the
infection or fever and should be done last.
DIF: Cognitive Level: Analyze (analysis)
OBJ: Special Questions: Prioritization
TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
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