A nurse is caring for a client who has a venous leg ulcer on the lower left calf. The nurse notes that the wound has copious amounts of yellow-green purulent drainage with a foul odor. The periwound skin is erythematous, warm, and edematous. The client reports increased pain and fever. What should the nurse do first?

Correct Answer: B

Rationale: Obtaining a wound culture and sensitivity is the correct first action for a venous leg ulcer with yellow-green purulent drainage, foul odor, erythema, edema, pain, and fever all signs of infection. Identifying the pathogen via culture guides antibiotic therapy, addressing the root cause before complications like sepsis escalate, critical in venous ulcers with poor healing potential. Compression bandages aid venous return but are secondary until infection is managed, as pressure could worsen an active infection. Analgesics and antipyretics treat symptoms, not the infection, delaying essential diagnostics. Elevation reduces edema but doesn't tackle the infection directly. Culturing first ensures targeted treatment, aligning with priority-setting in wound care to resolve infection swiftly.

Correct Answer: B

Rationale: Acute wound,' as it describes a wound that heals quickly (days to weeks) with well-approximated edges and reduced infection risk. Acute wounds, like cuts or surgical incisions, follow a predictable healing trajectory due to minimal tissue loss and prompt repair, often via primary intention. 'Abrasion wound' is a type of injury (scraping), not a healing classification, and may heal slower if extensive. 'Chronic wound' persists beyond weeks, often due to underlying conditions like diabetes, contradicting quick healing. 'Unintentional wound' defines cause (accidental), not healing speed or edge alignment. In nursing, identifying acute wounds guides timely interventions e.g., suturing versus chronic wounds needing prolonged care. B aligns with the description's focus on healing dynamics, distinguishing it as the accurate classification over specific wound types or causation.

Correct Answer: C

Rationale: Pain,' as it's a physical, not psychological, effect of wounds. Pain results from nerve stimulation at the injury site, a sensory response, whereas psychological effects impact mental state. 'Anxiety' is psychological, reflecting worry about healing or outcomes. 'Fear' involves emotional dread, perhaps of complications. 'Changes in body image' affect self-perception, a mental shift. In nursing, distinguishing these aids holistic care pain requires analgesics, while anxiety might need counseling. The question's focus on psychological effects excludes C, as pain's physical nature contrasts with the emotional impacts of A, B, and D, aligning with wound care's mind-body framework.

Correct Answer: D

Rationale: B and C,' as 'pressure ulcers' and 'bedsores' synonymous terms are among the most common skin and tissue disruptions, especially in immobile or elderly patients. They result from sustained pressure impairing blood flow, leading to tissue necrosis, with high prevalence in hospitals and long-term care. 'Maceration' is skin softening from prolonged moisture (e.g., incontinence), common but less frequent than pressure-related issues in broader statistics. 'Pressure ulcers' and 'bedsores' overlap, reinforcing their dominance. 'A and B' excludes bedsores' synonymy, underrepresenting the category. In nursing, preventing pressure ulcers via repositioning is a priority due to their frequency and complications (e.g., infection). E correctly pairs B and C, aligning with clinical data on skin disruption prevalence.