What complication of wound healing is an abnormal passage that connects two body cavities or a cavity and the skin?

Choice A reason: Shearing or friction is the force that caused the injury, because it occurs when the skin and underlying tissues move in opposite directions, such as when the client slides down in bed. Shearing or friction can damage the blood vessels and reduce blood flow to the skin, resulting in tissue ischemia, necrosis, and ulceration.

Choice B reason: Pressure or gravity is not the force that caused the injury, because it occurs when the skin and underlying tissues are compressed between a bony prominence and an external surface, such as when the client lies on his back. Pressure or gravity can impair blood flow and oxygen delivery to the skin, resulting in tissue damage and ulceration.

Choice C reason: Chemical or pressure is not the force that caused the injury, because it occurs when the skin is exposed to a substance that causes irritation, inflammation, or corrosion, such as when the client has a wound dressing that contains an antiseptic or a topical agent. Chemical or pressure can damage the skin barrier and increase the risk of infection and delayed wound healing.

Choice D reason: Twisting and bending is not the force that caused the injury, because it occurs when the skin and underlying tissues are stretched or distorted, such as when the client twists his ankle or bends his knee. Twisting and bending can cause sprains, strains, or tears of the ligaments, tendons, or muscles.

Choice A reason: Send the client back to surgery is not the nurse's next action, because it is premature and inappropriate. Sending the client back to surgery requires a medical order and a clear indication of the need for surgical intervention. The nurse cannot make this decision without first assessing the wound and contacting the provider.

Choice B reason: Call the provider immediately is not the nurse's next action, because it is not the most urgent and relevant. Calling the provider immediately is an important action, but it should be done after assessing the wound and gathering the necessary data. The nurse should be able to report the findings of the wound assessment, such as the size, shape, color, amount, and type of drainage, as well as the vital signs, pain level, and mental status of the client.

Choice C reason: Assess the wound for signs of dehiscence is the nurse's next action, because it is the most urgent and relevant. Assessing the wound for signs of dehiscence is a priority action, because it can identify the cause and severity of the problem. Dehiscence is a complication that occurs when the surgical incision splits open or separates, which can cause increased drainage, pain, and infection. Dehiscence can be caused by factors such as infection, poor wound healing, excessive strain, or trauma. Dehiscence can be detected by inspecting the wound for gaps, edges, or protrusions.

Choice D reason: Prepare to culture the wound is not the nurse's next action, because it is not the most urgent and relevant. Preparing to culture the wound is a possible action, but it should be done after assessing the wound and contacting the provider. Culturing the wound is a procedure that involves collecting a sample of the wound drainage and sending it to the laboratory for analysis, which can help identify the type and source of infection. Culturing the wound requires a medical order and a sterile technique.