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The nurse realizes that the patient with a shoulder incision needs more teaching when the patient says
- A. I know the signs of infection and will report them to the physician if they occur.'
- B. If my fever goes above 100 degrees, I will notify my doctor.'
- C. I know how to change the dressing on my incision and have done it three times.'
- D. I will take these antibiotics until the doctor removes the staples.'
Correct Answer: D
Rationale: Antibiotics should be taken for the full prescribed course, not until staples are removed, indicating a need for further teaching.
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Classify the following wounds as either open or closed: A. Contusion, B. Abrasion, C. Laceration, D. Pressure injury
- A. A: Closed, B: Open, C: Open, D: Open
- B. A: Open, B: Closed, C: Closed, D: Closed
- C. A: Closed, B: Closed, C: Open, D: Open
- D. A: Open, B: Open, C: Closed, D: Closed
Correct Answer: A
Rationale: Contusions are closed (bruising under intact skin), while abrasions, lacerations, and pressure injuries are open (skin is broken).
A patient with an open leg wound has the following laboratory results on his chart: WBC 15,350 mm^3 with an elevated percentage of neutrophils. What does this tell you about the patient's wound?
- A. He most likely no longer has any wound infection.
- B. He most likely has an acute wound infection.
- C. He most likely has a chronic wound infection.
- D. He most likely has a widespread bacterial infection.
Correct Answer: B
Rationale: Elevated WBC and neutrophils indicate an active immune response, typically seen in acute infections, suggesting the wound is acutely infected.
A colonized wound is one in which
- A. There is potential for becoming infected.
- B. Infection is present as a result of gross contamination related to trauma.
- C. Infection is present as evidenced by high numbers of microorganisms and either purulent drainage or necrotic tissue.
- D. A high number of microorganisms are present without signs and symptoms of infection.
Correct Answer: D
Rationale: A colonized wound has many microorganisms but no clinical signs of infection, distinguishing it from an infected wound.
Which of these factors affect wound healing?
- A. Positive attitude
- B. Chronic illness
- C. Medications
- D. Atmospheric pressure
- E. Diabetes mellitus
- F. Age
Correct Answer: B,C,E,F
Rationale: Chronic illness, medications, diabetes, and age impair immune response, tissue repair, or blood flow, delaying wound healing.
All of the following are found during your assessment of a surgical wound. Which would concern you the most?
- A. Edges of the wound are together except for a 1-cm area at the distal end, which is open approximately 1.5 cm.
- B. All sutures are intact, but one suture is somewhat looser than the other sutures.
- C. The 2-cm margin around the wound is red, warm, and swollen.
- D. The patient complains of increasing pain in the incisional area compared to yesterday.
Correct Answer: C
Rationale: Redness, warmth, and swelling around the wound margin are signs of infection, which is most concerning and requires prompt intervention.