A nurse is assessing a client who has a pressure ulcer on the sacrum. Which finding should the nurse report to the wound care specialist?

Correct Answer: B

Rationale: Yellowish-green drainage is the correct finding to report to the wound care specialist, as it strongly suggests infection or necrosis in the pressure ulcer. This purulent exudate, often tied to bacterial presence like Pseudomonas or Staphylococcus, requires urgent evaluation, possibly a culture, and treatment to prevent worsening or systemic spread. Foul odor may hint at infection or anaerobic bacteria but isn't definitive alone, as some wounds smell without being infected, making it less specific. Granulation tissue is a positive healing sign, not a concern, indicating new tissue formation. Partial-thickness skin loss aligns with pressure ulcer staging (e.g., Stage 2) and isn't an acute issue to report unless deteriorating. The yellowish-green drainage stands out as a critical, actionable finding, necessitating specialist input to address potential infection and optimize care.

Correct Answer: D

Rationale: 16,800 mL, based on the Parkland formula for burn fluid resuscitation: 4 mL of lactated Ringer's per kg of body weight per percentage of TBSA burned, given over 24 hours (half in the first 8 hours, half in the next 16). For a 70 kg client with 30% TBSA: 4 mL × 70 kg × 30 = 8,400 mL. However, the total 24-hour volume is often miscalculated; the formula yields 8,400 mL correctly, but the question's options suggest a doubled intent, possibly an error. Assuming intent aligns with standard Parkland (8,400 mL), none match perfectly, yet D (16,800 mL) might reflect a misprint. Still, 8,400 mL is accurate: 4,200 mL first 8 hours, 4,200 mL next 16. Given options, D is closest to a plausible high-end miscalculation, but 8,400 mL is technically right.

Correct Answer: D

Rationale: None of the above,' since the dermis contains all listed components: connective tissue, nerves, hair, and blood vessels. The dermis, the skin's thick middle layer, is primarily connective tissue, giving it strength and flexibility, with collagen and elastin fibers. Nerves within it enable sensation, detecting touch and pain, while hair follicles (producing hair) originate here, rooted in its structure. Blood vessels supply oxygen and nutrients, supporting its vitality. No option excludes a true component; 'Connective tissue' (A), 'Nerves' (B), 'Hair' (C), and 'Blood vessels' (D) are all present, making any single exclusion incorrect. In nursing, understanding the dermis's composition is key for wound care, as its elements influence healing connective tissue aids repair, nerves signal pain, hair indicates regrowth potential, and vessels ensure perfusion. Thus, 'None of the above' reflects the dermis's inclusive anatomy accurately.

Correct Answer: C

Rationale: Secondary intention,' as it describes large or open wounds, like burns or major trauma, left to heal naturally without edge approximation. These wounds, with significant tissue loss, fill in via granulation tissue and epithelialization from the base up, a slower process prone to scarring but suited for extensive damage. 'Primary intention' requires closed edges, impossible with large gaps. 'Delayed primary intention' involves eventual closure after initial openness, not leaving it alone entirely. 'Tertiary intention' also includes later surgical closure, not just natural healing. In nursing, secondary intention is key for managing burns dressings support granulation, not suturing. The question's focus on 'left alone' and large wounds aligns with C, distinguishing it from closure-based methods.

Correct Answer: A

Rationale: Primary intention,' as it describes Lois Griffin's heart transplant incision made deliberately, closed immediately with sutures post-surgery, promoting rapid healing with minimal scarring. Primary intention applies to clean, intentional wounds with edges approximated right after the procedure, typical in controlled surgical settings. 'Delayed primary intention' involves leaving the wound open briefly before closure, not immediate suturing as here. 'Secondary intention' is for wounds left open to heal naturally, unsuitable for a precise incision. 'Tertiary intention' combines initial openness with later closure, irrelevant to instant suturing. In nursing, primary intention is standard for surgeries like transplants, ensuring quick recovery and infection control. The question's focus on immediate closure rules out alternatives, making A the precise fit per wound healing classifications and surgical care protocols.