Chapter 20 Wounds

Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive
Outcomes, 7th Edition
Chapter 20: Clients with Wounds
MULTIPLE CHOICE
1. The nurse predicts that the wound capable of becoming “ideally healed” is a
a. lesion on the inside of the cheek.
b. burn scar on the leg.
c. severe acne on the face.
d. abdominal incision.
ANS: a
An “ideally healed” wound can occur only in epidermal tissue or mucous membranes. Once
there is injury through the dermis, scar tissue replaces the missing dermis and epidermis.
DIF: Cognitive Level: Knowledge REF: Text Reference: 397

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. Chemotaxis refers to
a. movement of leukocytes into an inflamed area.
b. collagen deposition and wound contraction.
c. mobility, differentiation, and growth of leukocytes.
d. cellular phagocytosis of foreign material.
ANS: a
Complement activation promotes inflammation and induces movement of leukocytes into the
area of injury through the process of chemotaxis.

TOP: Nursing Process Step: N/A MSC: NCLEX: N/A
3. When the body is subjected to invasion or trauma, the role of neutrophils is to

a. release an enzyme that destroys the cell membrane of parasites.
b. release histamine into the circulation.
c. produce specific antigens.
d. phagocytize injurious agents.
ANS: d
The role of neutrophils, along with tissue macrophages, is to phagocytize injurious agents.

TOP: Nursing Process Step: N/A MSC: NCLEX: N/A
4. The nurse explains that a client receiving long-term steroid therapy is at increased risk
for developing infections because steroid therapy causes
Elsevier items and derived items  2005 by Elsevier Inc.

Chapter 20: Clients with Wounds 2
a. a decrease in the number of neutrophils.

b. depression of the tissue macrophage system.
c. a decrease in the number of lymphocytes.
d. a decrease in the total number of macrophages.
ANS: c
Clients receivng steroid therapy have decreased numbers of lymphocytes. This change places the
steroid-dependent client at increased risk of infection and delayed healing.

TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
5. The edges of a client’s appendectomy incision are approximated, and no drainage is

noted. The nurse documents on the client’s wound record that the incision appears to
be healing by
a. primary intention.
b. secondary intention.
c. tertiary intention.
d. granulation.
ANS: a
Primary intention is the use of suture or other wound closures to approximate the edges of an
incision or a clean laceration.
DIF: Cognitive Level: Application REF: Text Reference: 402

6. The nurse who is using an enzymatic débridement ointment will

a. apply the ointment liberally over large areas.
b. keep the area moist after application.
c. use the ointment cautiously on neoplastic ulcers.
d. medicate the client before applying oinment to viable tissue.
ANS: b
Enzymatic agents work best in a moist environment. The oinment is applied to small areas and is
never applied to neoplastic leasions or viable tissue.
DIF: Cognitive Level: Analysis REF: Text Reference: 412

7. The nurse explains that capillaries dilate 10 to 30 minutes after injury, bringing extra
oxygen to the injured area in order to
a. carry phagocytes to the area effectively.
b. facilitate clot formation.
c. provide oxygen necessary for tissue hydration.
d. promote erythrocyte adherence to the target cell.
ANS: a

Capillary dilation allows ingress of plasma, which dilutes toxins secreted by the organism, brings
nutrients for tissue repair, and carries phagocytes into the area.
DIF: Cognitive Level: Comprehension REF: Text Reference: 398

8. The nurse advises the client that aspirin is often prescribed to decrease pain and
inflammation because of its effect for
a. constricting blood vessels.
b. decreasing histamine production.
c. decreasing permeability of blood vessels.
d. blocking production of prostaglandins.
ANS: d
Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) block the production of
prostaglandins and can assist in reducing inflammation and pain.

9. The nurse closely monitors a client with a streptococcal throat infection because
streptococci
a. are resistant to most antibiotics.
b. prevent the “walling off” effect and spread to other organs.
c. secrete an enzyme that produces extensive cellular damage.
d. break down the complement system and spread rapidly.
ANS: b
Streptococci do not cause an intense reaction in the tissues and can digest the walls. This allows
the streptococci to multiply and spread and thus invade other organs, such as the heart.

TOP: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment;
10. The nursing action most appropriate for a client who has an infection and develops a
fever of 99.8° F is to
a. continue to monitor the client’s temperature.
b. administer an antipyretic.
c. cool the client’s environment.
d. keep the client warm.
ANS: a
Fever is usually adaptive because bacterial reproduction is sensitive to even slight increases in
temperature.


11. In discussing diet modification, the nurse encourages a client with cellulitis and
severe inflammation to include
a. tea.
b. saltine crackers.
c. pretzels.
d. citrus fruits.
ANS: d
Protein, vitamins, carbohydrates, fats, trace elements, and fluids are necessary and play an
essential role in the wound-healing process. Of the options listed, citrus fruits have the greatest
amount of nutrients.

12. Twenty-four hours after surgery, the nurse assesses the development of a small
amount of sanguineous drainage and should
a. record this finding as normal.
b. closely observe the wound for dehiscence.
c. notify the physician immediately.
d. monitory for other manifestations of infection.
ANS: a
Small amounts of sanguineous drainage are expected after surgery or trauma. Large amounts
may indicate hemorrhage.

13. A client who sprained his ankle 1 hour ago is experiencing swelling and pain. The
nursing instruction most appropriate in dealing with these manifestations is
a. apply cold and heat, alternating every hour.
b. lower the ankle below the level of the heart to promote circulation.
c. apply heat to the area.
d. apply ice to the area for the first 24 hours, then apply heat.
ANS: d
Most practitioners advocate using ice to control the inflammatory response in the extremities for
long periods, especially when edema and pain are present. Some physicians order ice for 24
hours to control inflammation, then heat to remove the accumulated waste products.

14. On removing a dressing from a client on the third postoperative day, the nurse notes
thin, pink-colored drainage and documents this as
a. serous.

b. sanguineous.
c. serosanguineous.
d. purulent.
ANS: c
Serosanguineous exudate is drainage composed of both serous fluid and blood. It is pink and
usually fairly thin.

15. When caring for a client with a wound healing by secondary intention, the nurse
considers during care planning that this type of wound is
a. more susceptible to infection.
b. prone to dehiscence.
c. healed with the aid of skin grafts.
d. sealed with sutures.
ANS: a
Wounds healing by secondary intention require the regeneration of much more tissue than
wound healing by primary intention, and there is also increased risk of infection.

16. The nurse anticipates that the client most likely to experience a significant delay in
wound healing after surgery is
a. a woman receiving estrogen therapy.
b. a man with a history of allergic reactions.
c. a woman receiving steroid therapy.
d. a man on a low-fat diet.
ANS: c
The use of steroids slows healing by inhibiting collagen synthesis.

17. The nurse instructs a client that after surgery, negative effects of smoking that delay
wound healing are caused by
a. vasoconstriction and hypoxia.
b. decrease in platelet synthesis aggregation.
c. inhibited contraction and epithelialization.
d. impaired collagen synthesis and angiogenesis.
ANS: a

Of the many factors that promote or retard angiogenesis, one of the most important is adequate
oxygenation. Smoking causes vasoconstriction and hypoxia because of the carbon monoxide in
the smoke.

18. To assist in the healing of a large leg ulcer, the nurse applies wet dressings to the
wound to promote
a. chemotaxis.
b. angiogenesis.
c. epithelialization.
d. wound contraction.
ANS: c
Wound healing is optimized in a moist environment. When the environment is moist, collagen
synthesis and granulation tissue formation are enhanced, cell migration and epithelial resurfacing
occur more rapidly, and scab, crust, and eschar cannot form.

19. The nurse reminds the client that a nutrient necessary to prevent weakness of the
newly healed wound is
a. folate.
b. iron.
c. vitamin A.
d. vitamin C.
ANS: d
Impairments related to vitamin C deficiency are decreased collagen production, angiogenesis,
contraction, weakness in healed wounds, and increased risk of infection.

20. The nurse caring for a client with a large, sacral pressure ulcer with a red wound base
and no drainage would select as the most appropriate solution for cleansing this
wound
a. normal saline.
b. a weak iodine solution.
c. half-strength peroxide.
d. Dakin’s solution.
ANS: a
Normal saline (NS) is the only solution recommended by the American Healthcare Policy and
Research (AHCPR) group for wound care, such as in packing and cleaning. NS is physiologic,
will not harm tissues, and adequately cleans most wounds.


21. The nurse caring for a client receiving wet-to-dry dressings for mechanical
débridement of a large wound would be aware that proper technique requires that the
dressing
a. should be removed when it is totally dry.
b. should cause slight bleeding when removed to be effective.
c. should be left in place about 12 hours.
d. should only be moist, not wet, when applied.
ANS: d
Mechanical débridement can be accomplished by the use of wet-to-dry dressings. A moist (not
wet) dressing is positioned in the wound and held in place by an outer dressing or gauze wrap.

22. On a client’s admission to the hospital, the nurse notes that the client has a yellow
sacral decubitus ulcer. The nurse anticipates that the most appropriate wound
treatment would be
a. vigorous cleansing with a Water Pik.
b. applying antibiotic ointment.
c. using wet-to-dry dressings.
d. surgical removal of eschar.
ANS: c
Yellow material in the wound base is a sloughy, necrotic type of material. Before a wound can
heal, necrotic tissue must be removed. Mechanical débridement can be accomplished by using
wet-to-dry dressings.

23. A client has a small, shallow wound with a red base that does not require
débridement. The dressing that the nurse would choose when covering this wound is
a. dry woven gauze fastened with adhesive tape.
b. wet nonwoven gauze.
c. a nonadhering dressing (e.g., Telfa) with antibiotic ointment.
d. wet-to-dry gauze dressing.
ANS: c
If the wound is shallow, a thin layer of antibiotic ointment and a nonadhering dressing are used
to cover it.


24. The nurse assessing a client for a possible wound infection would recognize as an
indication of infection the finding of
a. serosanguineous drainage from the wound.
b. elevated band neutrophils in the serum.
c. absence of healing ridge.
d. leukopenia.
ANS: b
Immature cells are “banded” and are called bands. The presence of increased band neutrophils
indicates more severe infection because the bone marrow has released immature cells.

25. A client’s dressing orders include calcium alginate (Kalistat). The nurse instructs the
client that this application is appropriate for a(n)
a. red wound.
b. draining wound.
c. black wound.
d. infected wound.
ANS: b
Calcium alginate retains moisture and is left intact for 2 to 3 days as a treatment for a draining
wound.
DIF: Cognitive Level: Application REF: Text Reference: 410, Table 20-5;
26. The nurse explains to a wound client that in the healing process, growth factors
called cytokines function to
a. produce “ideal healing.”
b. interfere with the healing process.
c. provide an orderly sequence of healing.
d. inhibit the inflammatory phase of healing.
ANS: c
Cytokines serve to organize and provide an orderly sequence in the healing process.

TOP: Nursing Process Step: Intervention
MSC: NCLEX: Health Promotion and Maintenance
27. The nurse is aware that the process by which capillary permeability is altered to
allow the large neutrophils to pass through the capillary wall and to the wound site is
called
a. marginating.
b. segmenting.

c. banding.
d. replicating.
ANS: a
The capillaries are layered with cells that allow a gateway for the large neutrophils to exit the
capillary and enter the site of the wound to begin the inflammatory phase of healing.

TOP: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
28. Four days after a client’s surgery, the nurse assesses a collagen mass under the
client’s suture line as an indication of
a. infection.
b. healing ridge.
c. edema.
d. abscess.
ANS: b
A ridge of collagen forms under the suture line 3 to 5 days after the incision is made. This
collagenous mass is indicative of healing.

29. The nurse informs the client that to reduce scarring, facial sutures are removed in
a. 1 to 2 days.
b. 4 to 7 days.
c. 8 to 10 days.
d. 12 to 14 days.
ANS: b
Sutures in areas such as the face, where scarring is avoided, are removed within 4 to 7 days.

TOP: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity

Chapter 20 Wounds

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Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive

Outcomes, 7th Edition

Chapter 20: Clients with Wounds

DIF: Cognitive Level: Knowledge REF: Text Reference: 397

DIF: Cognitive Level: Knowledge REF: Text Reference: 401

3. When the body is subjected to invasion or trauma, the role of neutrophils is to

DIF: Cognitive Level: Knowledge REF: Text Reference: 400

Elsevier items and derived items  2005 by Elsevier Inc.

a. a decrease in the number of neutrophils.

DIF: Cognitive Level: Knowledge REF: Text Reference: 400

5. The edges of a client’s appendectomy incision are approximated, and no drainage is

DIF: Cognitive Level: Application REF: Text Reference: 402

6. The nurse who is using an enzymatic débridement ointment will

DIF: Cognitive Level: Analysis REF: Text Reference: 412

Elsevier items and derived items  2005 by Elsevier Inc.

DIF: Cognitive Level: Comprehension REF: Text Reference: 398

DIF: Cognitive Level: Comprehension REF: Text Reference: 400

DIF: Cognitive Level: Application REF: Text Reference: 399

DIF: Cognitive Level: Analysis REF: Text Reference: 406

Elsevier items and derived items  2005 by Elsevier Inc.

DIF: Cognitive Level: Application REF: Text Reference: 404

DIF: Cognitive Level: Application REF: Text Reference: 405

DIF: Cognitive Level: Application REF: Text Reference: 403

Elsevier items and derived items  2005 by Elsevier Inc.

DIF: Cognitive Level: Application REF: Text Reference: 405

DIF: Cognitive Level: Application REF: Text Reference: 402

DIF: Cognitive Level: Application REF: Text Reference: 400

Elsevier items and derived items  2005 by Elsevier Inc.

DIF: Cognitive Level: Application REF: Text Reference: 401

DIF: Cognitive Level: Application REF: Text Reference: 409

DIF: Cognitive Level: Application REF: Text Reference: 404

Elsevier items and derived items  2005 by Elsevier Inc.

DIF: Cognitive Level: Application REF: Text Reference: 409

DIF: Cognitive Level: Analysis REF: Text Reference: 411

DIF: Cognitive Level: Analysis REF: Text Reference: 411

DIF: Cognitive Level: Application REF: Text Reference: 410

Elsevier items and derived items  2005 by Elsevier Inc.

DIF: Cognitive Level: Application REF: Text Reference: 400

DIF: Cognitive Level: Comprehension REF: Text Reference: 397

Elsevier items and derived items  2005 by Elsevier Inc.

DIF: Cognitive Level: Comprehension REF: Text Reference: 400

DIF: Cognitive Level: Application REF: Text Reference: 401

DIF: Cognitive Level: Application REF: Text Reference: 406

Elsevier items and derived items  2005 by Elsevier Inc.

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