A nurse is assessing a client with a pressure ulcer on the sacrum. Which finding should the nurse report to the provider immediately?

Correct Answer: A

Rationale: Foul odor and purulent drainage is the correct finding to report immediately, as it signals an acute infection in the pressure ulcer. This combination suggests bacterial proliferation, potentially leading to sepsis or deeper tissue damage, requiring urgent provider intervention, wound culture, and possibly antibiotics. Black, necrotic tissue indicates eschar, which needs debridement but isn't immediately life-threatening unless unstable or infected, manageable by the wound team. Red, granulating tissue is a healthy sign of healing, not a concern. Yellow, sloughing tissue represents slough, which delays healing but isn't an emergency unless paired with infection signs. The foul odor and purulent drainage escalate the situation to critical, demanding prompt reporting to prevent systemic complications, distinguishing it as the priority among these findings.

Correct Answer: C

Rationale: Primary intention wound is the correct documentation for a wound with approximated edges, minimal drainage, and visible granulation tissue. This healing type occurs when edges are closed (e.g., by sutures), minimizing tissue loss and scarring, with granulation supporting epithelialization. Partial-thickness involves only epidermis and part of dermis, healing by regeneration, not matching the deeper granulation here. Full-thickness extends to subcutaneous layers, healing with significant scarring, not minimal drainage. Secondary intention involves open wounds with extensive loss, healing slowly via granulation and contraction, not approximated edges. Primary intention fits the orderly, efficient healing observed, reflecting a controlled closure process typical of surgical or well-managed wounds.

Correct Answer: D

Rationale: A and C,' as unintentional wounds are characterized by being accidental and often having clean edges, depending on the cause. 'Accidental' fits because unintentional wounds result from unplanned events like falls or cuts, not deliberate actions like surgery. 'Clean edges' applies to wounds from sharp objects (e.g., a knife slice), common in accidents, though not universal jagged edges can occur too. 'High risk for infection' isn't exclusive to unintentional wounds; it depends on contamination, not intent, and intentional wounds (e.g., surgical) can also get infected if mishandled. Combining A and C captures key traits without overgeneralizing infection risk. In nursing, recognizing these features aids assessment accidental wounds may need tetanus prophylaxis, and clean edges suggest primary closure potential. 'All of the above' (E) overstates infection specificity, making D the precise choice per wound classification principles.

Correct Answer: D

Rationale: Obtain clean towels,' as it's a mistake in managing dehiscence a surgical wound reopening. Proper protocol requires sterile materials (e.g., saline-moistened sterile dressings) to cover the wound, preventing contamination, not just clean towels, which may harbor bacteria. 'Notify the physician' is correct urgent reporting is essential. 'All of the above have mistakes' is wrong, as A is valid. 'None of the above have mistakes' overlooks D's error. In nursing, sterility is critical in dehiscence to avoid infection or evisceration; clean towels fail this standard. The document lists 'Moisten towels with sterile 0.9% sodium chloride' separately, implying D's non-sterile intent is the flaw, making it the mistaken step.

Correct Answer: C

Rationale: All of the above,' as 'decubitus ulcer' and 'bedsore' are both synonyms for 'pressure ulcer.' All describe localized skin and tissue damage from prolonged pressure, often over bony prominences, common in bedridden patients. 'Decubitus ulcer' derives from Latin for 'lying down,' emphasizing position-related etiology. 'Bedsore' is a colloquial term for the same condition, highlighting its association with immobility. 'All of the above' captures their interchangeability in medical and lay contexts. 'None of the above' is incorrect terminology aligns across nursing texts. In practice, recognizing these terms ensures clear communication e.g., documenting 'decubitus ulcer' or educating families about 'bedsores.' C's inclusivity matches the question's intent, reflecting standard wound care vocabulary.