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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

Explanation

A. Use a cuff of the appropriate size for the client:
Using a cuff that is too small or too large can cause inaccurate readings. Proper sizing is crucial.

B. Assist the client to the bathroom to void:
While a full bladder can slightly affect BP, this is not the most essential step to ensure an accurate reading.

C. Apply the cuff loosely around the client’s arm:
A loose cuff will cause an inaccurate (falsely high) reading.

D. Obtain the reading in the early morning:
While BP naturally varies, the time of day is not critical to accurate technique unless part of a specific assessment schedule.

Correct Answer is C

Explanation

A. Full thickness skin loss with visible bone:
This describes a stage 4 pressure injury.

B. Full thickness skin loss with visible adipose tissue:
This describes a stage 3 pressure injury.

C. Partial-thickness skin loss with red tissue in wound bed:
Stage 2 pressure injuries involve partial-thickness skin loss, sometimes with a pink or red wound bed and may include blistering.

D. Intact skin with localized erythema:
This describes a stage 1 pressure injury.

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