A nurse is caring for a client who has a pressure injury. Exhibits Click to highlight the documentation in the client's medical record that requires further action by the nurse. To deselect information, click on the information again. Day 4: Hydrocolloid dressing removed. Client has a 2.5 cm (1 in) x 3 cm (1.2 in) stage 3 pressure injury on left heal. Increased redness at wound borders and purulent drainage noted. Temperature 38.9° C (102° F) BP 118/56 mm Hg Heart rate 102/min Respiratory rate 22/min Pulse oximetry 95% on room air Hct 38% (37% to 47%) Hgb 12 g/dl (12 g/dL to 16 g/dL) WBC 12,000/mm (5,000 to 10,000 mm)

Rationale for Correct Answers: Client has a 2.5 cm (1 in) x 3 cm (1.2 in) stage 3 pressure injury on left heel: The wound has increased in size from 2.0 cm to 2.5 cm, indicating worsening tissue damage. Progression in wound size suggests ineffective treatment and warrants reassessment of the care plan. Increased redness at wound borders: New or worsening erythema around the wound border is a sign of local infection or inflammation. This finding suggests that the wound environment may be contaminated or inflamed. Purulent drainage noted: The presence of thick, colored exudate indicates bacterial infection at the wound site. This type of drainage typically requires culture, new dressing orders, and possibly antibiotics. Temperature 38.9°C (102°F): This elevated temperature indicates a febrile response, often associated with systemic infection. The fever, along with local wound signs, may point to cellulitis or sepsis risk. WBC 12,000/mm³: A white blood cell count above the normal range reflects systemic inflammation or infection. When coupled with fever and purulence, this reinforces the need for urgent evaluation and treatment. Rationale for Incorrect Choices: BP 118/56 mm Hg: This minimal change in blood pressure from 128 to 118, is not a primary indicator of a problem requiring immediate "further action" in the context of the other, more striking findings. Pulse oximetry 95% on room air: This oxygen level is within the normal range and indicates adequate gas exchange. It does not point to respiratory distress or infection-related hypoxia. Hgb 12 g/dL and Hct 38%: Both values are within the reference range for women and do not indicate anemia or bleeding. They are not relevant to infection progression or pressure injury management.