A patient from a long-term care facility is admitted to the hospital with a sacral pressure injury. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure injury?

Choice A reason: Fluid restrictions are not appropriate for stabilizing a patient with acute anemia. In fact, patients with anemia might require fluid resuscitation to maintain adequate blood volume and pressure. Restricting fluids could potentially worsen the patient's condition.

Choice B reason: Iron supplements are necessary for patients with acute anemia, especially if the anemia is due to iron deficiency. Supplementation helps replenish iron stores in the body, aiding in the production of hemoglobin and red blood cells which are critical for carrying oxygen to tissues.

Choice C reason: PRBC (Packed Red Blood Cells) transfusion is a common and effective intervention for acute anemia. It quickly increases the number of red blood cells in the patient's circulation, thereby improving oxygen delivery to tissues and alleviating symptoms of anemia such as fatigue and weakness.

Choice D reason: O2 therapy, or oxygen therapy, is crucial for stabilizing patients with acute anemia. Anemia results in reduced oxygen-carrying capacity of the blood, and supplemental oxygen helps ensure that tissues receive sufficient oxygen. This intervention can be lifesaving in severe cases of anemia.

Choice A reason: Amber fluid is typically a sign of serous exudate, which is a normal part of the inflammatory process and wound healing. It indicates the body's immune response to the injury and is generally not a cause for concern unless the volume significantly increases or changes in appearance.

Choice B reason: Clear drainage, or serous fluid, is also a normal finding in wound healing. It indicates that the wound is exuding plasma, which helps to keep the wound moist and supports the healing process. This type of drainage is typically not worrisome unless there are other signs of infection or complications.

Choice C reason: Purulent, draining wound is a major concern as it indicates the presence of pus, which is often a sign of infection. Purulent drainage can be yellow, green, or brown and is usually thick and malodorous. The presence of pus suggests that there are bacteria or other pathogens in the wound, and immediate medical intervention is necessary to prevent further complications and promote healing.

Choice D reason: Blood-tinged fluid, or serosanguinous drainage, is common in fresh wounds or after debridement. It indicates a mixture of plasma and red blood cells and can be seen in the early stages of wound healing. While it is generally not alarming, the nurse should monitor the volume and changes in the drainage to ensure there are no signs of excessive bleeding or infection.