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 Pink, shiny tissue with a granular appearance describes granulation tissue, which is comprised of new blood vessels and connective tissue. This finding indicates the proliferative phase of wound healing and is a sign of normal, healthy progression in a wound healing by secondary intention. This characteristic would not necessitate reporting to the charge nurse. Choice B rationale A halo of erythema (redness) on the surrounding periwound skin suggests inflammation or infection. Erythema is caused by local vasodilation in response to microbial invasion or tissue injury. In an open wound, this is a key sign of developing cellulitis or wound infection, requiring immediate evaluation, potential culture, and antibiotic treatment, thus it must be reported. Choice C rationale Serosanguineous drainage is a common and expected type of wound drainage, especially during the inflammatory and proliferative phases. It is a thin, pink-to-light-red fluid composed of both serous fluid (clear, watery) and blood (sanguineous). While excessive drainage may be concerning, the presence of serosanguineous drainage itself is typically normal. Choice D rationale Tenderness to touch is common in any healing wound, especially a deep one healing by secondary intention, due to tissue manipulation and the ongoing inflammatory process, which involves chemical mediators stimulating nociceptors. While severe or increasing pain is concerning, general tenderness is expected and not an immediate sign of complication unless accompanied by other infectious signs.