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Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Exhibits

Wound bed is red.

Redness noted at wound borders, skin surrounding wound is warm to touch

purulent drainage noted

Temp 38.9° C (102° F)

Hct 37% (37% to 47%)

WBC 13,500/mm3 (5000 to 10,000 mm3)
 

A.

Wound bed is red.

B.

Redness noted at wound borders, skin surrounding wound is warm to touch

C.

purulent drainage noted

D.

Temp 38.9° C (102° F)

E.

WBC 13,500/mm3 (5000 to 10,000 mm3)

Answer and Explanation

The Correct Answer is ["B","C","D","E"]

The findings that require follow-up:

  • Redness noted at wound borders, skin surrounding wound is warm to touch
     This suggests local infection or inflammation around the wound.
  • Purulent drainage noted
     Purulent (thick, discolored) drainage is a sign of infection and requires prompt follow-up.
  • Temp 38.9° C (102° F)
     This elevated temperature indicates a systemic response, likely due to infection.
  • WBC 13,500/mm³ (5000 to 10,000 mm³)
     This is an elevated WBC count, consistent with infection or inflammation.

Incorrect answers:

  • Wound bed is red
     A red wound bed in a pressure injury is often a sign of granulation tissue, which is part of the normal healing process, not a concern unless accompanied by other signs of infection.
  • Hct 37% (37% to 47%)
     Hematocrit is within normal limits, and does not indicate concern.


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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Explanation

Finding

Assessment

Rationale

Temperature: 38.6°C

Worsened

The temperature increased from 38.2°C to 38.6°C, suggesting worsening fever or infection.

Pulse oximetry: 95% on 40% O₂

Improved

The client’s oxygen saturation increased from 85% to 95%, though with supplemental O₂, showing improved oxygenation.

Respiratory rate: 22/min

Improved

RR decreased from 32 to 22, indicating better respiratory effort and less distress.

Blood pressure: 112/54 mmHg

Unchanged

Minimal change from 114/56 to 112/54; both readings are within similar ranges.

Mucous membrane color: pink

Improved

Pink mucous membranes indicate improved oxygenation and perfusion, compared to pale earlier.

Correct Answer is ["A","B","C","D","E"]

Explanation

T 38°C (100.4°F), oral
The temperature has decreased from 38.9°C to 38.0°C, showing improvement in fever, likely due to rehydration and reduced systemic inflammation.

BP 106/60 mm Hg, supine
Blood pressure has improved from a hypotensive state (88/56) to a more stable reading, indicating effective fluid resuscitation.

HR 99/min
Heart rate decreased from 112/min to 99/min, indicating reduced compensatory tachycardia, likely due to improved fluid volume status.

R 20/min
Respiratory rate is within normal limits and stable; no signs of respiratory compromise.

Pulse oximetry 95% on room air
Oxygen saturation is maintained within normal range without supplemental oxygen, indicating adequate perfusion and oxygenation.

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