A nurse is collecting data on a client who has a surgical wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse?

Choice A rationale A halo of erythema on the skin surrounding a wound is a clinical sign of cellulitis or a localized spreading infection that must be reported. While some redness is normal during the inflammatory phase, a distinct halo suggests that bacteria are invading the healthy tissue around the wound site. Prompt reporting allows the charge nurse and provider to evaluate the need for topical or systemic antibiotics to prevent further systemic complications or delayed healing. Choice B rationale Serosanguineous drainage consists of a mixture of serum and red blood cells, appearing as thin, watery, and pale red or pink fluid. This is a normal finding in a healing surgical wound, especially during the first few days after the procedure. It indicates that the wound is progressing through the expected stages of healing and does not typically signify an infection or a complication that requires urgent reporting to the charge nurse or the physician. Choice C rationale Pink, shiny tissue with a granular or bumpy appearance is known as granulation tissue. This is a very positive sign in a wound healing by secondary intention, as it indicates that the wound bed is being filled with new connective tissue and microscopic blood vessels. Granulation tissue is highly vascular and represents the proliferative phase of wound healing. Because this is a healthy and expected finding, it does not need to be reported as a concern. Choice D rationale Tenderness to touch is a common and expected finding in a surgical wound, especially one that is healing by secondary intention. This method of healing involves a larger wound area that remains open to fill with granulation tissue, which naturally involves inflammation and nerve sensitivity. While extreme or worsening pain should be monitored, general tenderness during the healing process is normal and does not necessarily indicate a complication like infection or dehiscence requiring immediate reporting.