A nurse is caring for a client in a wound center. Exhibits Click to highlight the findings that indicate therapy has been ineffective. To deselect a finding, click on the finding again. Nurses' Notes Today: Client presents for evaluation of wound vac therapy that was applied to surgical wound on their left knee 1 week ago. Cilent rates pain as 8 on a scale of 0 to 10 in their left knee. Client reports no relief with pain medications. Respirations even and nonlabored. Heart rate regular and fast. Abdomen soft and nondistended. Left knee wound vac dressing removed. Left knee wound is 3 cm by 2 cm with 1 cm depth, Wound bed vascular with some approximation of the edges. Mild purulent drainage noted.

Rationale: Client rates pain as 8 on a scale of 0 to 10 in their left knee. Client reports no relief with pain medications. The client’s pain has worsened from 4/10 despite pain medication, indicating the current pain management approach is ineffective, and the wound may not be healing as expected. Mild purulent drainage noted: The presence of purulent drainage is a sign of infection, further indicating that the wound vac therapy has not been successful in preventing or managing infection at the wound site. Left knee wound is 3 cm by 2 cm with 1 cm depth, compared to 2 cm by 2 cm with 1 cm depth one week ago: The increase in wound sizefrom 2cm by 2 cm to 3 cm by 2 cm suggests that the wound vac therapy is not promoting healing effectively, leading to a failure of wound closure. Rationale for Incorrect Choices: Wound bed vascular with some approximation of the edges: The wound bed being vascular with some approximation of the edges indicates that there is some healthy tissue and the edges of the wound are coming together. This suggests that some healing is occurring, although it may be slower than expected.