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Principles of Basic Wound Care
Principles of Basic Wound Care ( 4 Questions)
A nurse is assessing a client with a pressure ulcer on the sacrum. Which finding indicates a potential complication of the wound?
This is a normal finding, as serous drainage is clear and watery and indicates a healthy inflammatory response.
This is a normal finding, as redness and warmth indicate increased blood flow to the wound site, which facilitates healing.
Rationale: Foul-smelling greenish discharge from the wound indicates a possible infection, which can delay wound healing and increase the risk of sepsis. The nurse should notify the provider and obtain a wound culture to identify the causative organism and guide antibiotic therapy.
This is a positive finding, as granulation tissue is new connective tissue that fills the wound and supports epithelialization.
Correct answer: C) Foul-smelling greenish discharge from the wound
Rationale: Foul-smelling greenish discharge from the wound indicates a possible infection, which can delay wound healing and increase the risk of sepsis. The nurse should notify the provider and obtain a wound culture to identify the causative organism and guide antibiotic therapy.
Incorrect options:
A) Serous drainage from the wound - This is a normal finding, as serous drainage is clear and watery and indicates a healthy inflammatory response.
B) Redness and warmth around the wound - This is a normal finding, as redness and warmth indicate increased blood flow to the wound site, which facilitates healing.
D) Granulation tissue forming in the wound bed - This is a positive finding, as granulation tissue is new connective tissue that fills the wound and supports epithelialization.