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    HESI Compass exit proctored exam

    A client with a non-healing wound and excessive drainage is using a wound VAC system. The nurse notices increased drainage and signs of possible infection. What is the most appropriate nursing intervention?

    Explanation & Rationale

    Choice A reason: Increasing the wound VAC suction may help with drainage but does not address the underlying issue that might require specialist evaluation. Choice B reason: Consulting the wound care specialist to evaluate the wound ensures that the client receives expert assessment and appropriate recommendations for care. Choice C reason: Cleansing the wound and discontinuing the VAC system is not an appropriate action without specialist input. Choice D reason: Reapplying the VAC system after irrigating away drainage may be necessary, but it should be done based on the specialist’s recommendations. Choice E reason: Documenting the wound measurements with tunneling is important for record-keeping but does not address the immediate issue of evaluating the wound.

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