A nurse is assessing a client who has a pressure ulcer on the sacrum. Which finding indicates a possible infection of the wound?

Serous drainage

Reddened periwound skin

Increased pain and tenderness

Granulation tissue formation

Answer and Explanation

The Correct Answer is C

Correct answer: C) Increased pain and tenderness

Rationale: Increased pain and tenderness of the wound site may indicate an infection, as the inflammatory response is triggered by the presence of microorganisms. The nurse should obtain a wound culture and notify the provider of the suspected infection.

Incorrect options:

A) Serous drainage - This is a normal finding for a healing wound, as serous fluid is clear and watery and contains plasma and white blood cells. It does not indicate an infection unless it is cloudy, foul-smelling, or purulent.

B) Reddened periwound skin - This is a normal finding for a healing wound, as the increased blood flow to the area promotes oxygen and nutrient delivery to the wound site. It does not indicate an infection unless the redness is spreading, warm, or accompanied by other signs of inflammation.

D) Granulation tissue formation - This is a normal finding for a healing wound, as granulation tissue is new connective tissue that fills the wound bed and supports epithelialization. It does not indicate an infection unless it is pale, friable, or necrotic.

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Correct Answer is A

Explanation

Correct answer: A) Autograft

Rationale: An autograft is a type of skin graft that uses the client's own skin as the donor site. This is the preferred type of graft, as it has the lowest risk of rejection and infection, and provides the best cosmetic and functional results.

Incorrect options:

B) Allograft - This is a type of skin graft that uses human skin from a cadaver or a living donor as the donor site. This type of graft is used as a temporary measure to cover large wounds until an autograft is available.

C) Xenograft - This is a type of skin graft that uses animal skin, usually from pigs, as the donor site. This type of graft is also used as a temporary measure to protect wounds from infection and fluid loss until an autograft is available.

D) Mesh graft - This is a type of skin graft that involves making small slits in the donor skin to create a mesh-like pattern. This allows the graft to cover a larger area and conform to irregular surfaces. This type of graft can be either an autograft or an allograft.

A. Eschar B. Slough C. Fibrin D. Exudate

Correct Answer is A

Explanation

Correct answer: A) Eschar

Rationale: Eschar is dead tissue that is black, dry, and hard and adheres firmly to the wound bed or ulcer edges. It may be stable (dry, adherent, intact without erythema or fluctuance) or unstable (loose, moist, boggy, edematous). Stable eschar on the heels serves as the body's natural cover and should not be removed. Unstable eschar in infected wounds should be debrided to expose viable tissue.

Incorrect options:

B) Slough - This is dead tissue that is yellow, tan, gray, green, or brown and has a moist, stringy, or mucinous appearance. It may be loosely attached or firmly adherent to the wound bed. It should be removed to promote wound healing.

C) Fibrin - This is a protein involved in blood clotting that forms a mesh-like structure to seal the wound and stop bleeding. It may appear as a yellowish-white film on the wound surface. It should not be confused with slough or pus.

D) Exudate - This is fluid that leaks out of blood vessels into the surrounding tissues due to inflammation or injury. It may have different characteristics depending on the type and stage of the wound. It should be managed to maintain a moist but not wet wound environment.

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A nurse is assessing a client who has a pressure ulcer on the sacrum. Which finding indicates a possible infection of the wound?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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