A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught. What is the priority nursing action?

Choice A reason: Color is a characteristic of exudate that should be included when documenting it. Color can indicate the type and severity of the wound infection or inflammation. For example, yellow or green exudate may indicate a bacterial infection, while red or brown exudate may indicate bleeding or necrosis.

Choice B reason: Odor is a characteristic of exudate that should be included when documenting it. Odor can indicate the presence and type of microorganisms in the wound. For example, a foul or putrid odor may indicate anaerobic bacteria, while a sweet or fruity odor may indicate pseudomonas.

Choice C reason: Heat is not a characteristic of exudate that should be included when documenting it. Heat is a sign of inflammation that can be assessed by palpating the skin around the wound, not by observing the exudate. Heat does not directly reflect the quality or quantity of the exudate.

Choice D reason: Consistency is a characteristic of exudate that should be included when documenting it. Consistency can indicate the viscosity and composition of the exudate. For example, thin or watery exudate may indicate a serous or serosanguineous fluid, while thick or creamy exudate may indicate a purulent or fibrinous fluid.

Choice E reason: Amount is a characteristic of exudate that should be included when documenting it. Amount can indicate the extent and stage of the wound healing process. For example, a large amount of exudate may indicate a high level of inflammation or infection, while a small amount of exudate may indicate a low level of inflammation or infection.

Choice A reason: Inflammation is not an example of a client's primary defense to infection. Inflammation is a secondary defense to infection, which is activated after the primary defense has been breached. Inflammation is a complex process that involves the release of chemical mediators, the dilation of blood vessels, the increase of blood flow, the migration of white blood cells, and the formation of exudate. Inflammation aims to contain, neutralize, and eliminate the infectious agent and to repair the damaged tissue.

Choice B reason: Fever is not an example of a client's primary defense to infection. Fever is a secondary defense to infection, which is activated after the primary defense has been breached. Fever is an elevation of the body temperature above the normal range, which is usually 36.5 to 37.5 degrees Celsius or 97.7 to 99.5 degrees Fahrenheit. Fever is a systemic response to infection that is regulated by the hypothalamus, which is the part of the brain that controls the body's thermostat. Fever enhances the immune system's activity and inhibits the growth of some pathogens.

Choice C reason: Phagocytosis is not an example of a client's primary defense to infection. Phagocytosis is a secondary defense to infection, which is activated after the primary defense has been breached. Phagocytosis is a process that involves the engulfment and destruction of foreign particles, such as bacteria, by specialized cells, such as macrophages and neutrophils. Phagocytosis is a type of cellular immunity that eliminates the infectious agent and prevents its spread.

Choice D reason: Intact skin is an example of a client's primary defense to infection. Intact skin is the first and most important line of defense against infection, as it forms a physical barrier that prevents the entry of pathogens into the body. Intact skin also has chemical and biological properties that resist infection, such as the acidic pH, the secretion of sebum and sweat, and the presence of normal flora. Intact skin protects the underlying tissues and organs from infection and injury.