A client with an infected four-day-old postoperative wound has ...

[geoffrey]

A client with an infected four-day-old postoperative wound has been readmitted to the unit for wound debridement and antibiotic therapy.
 
  The wound is sutured with a scab that is pulling away from the edges of the skin, is draining pus and serosanguinous fluid, and is swollen and reddened. The nurse classifies the wound at what stage of healing? 1. Secondary intention healing
  2. Proliferative phase
  3. Maturation phase
  4. Inflammatory phase

Question 2

During data collection, the nurse identifies the following as subjective data:
 
  1. Laughing during interview
  2. I feel so dizzy
  3. My dressing is bloody
  4. Temperature is 100.2
  5.

[scikid]

Answer to Question 1

4
Rationale: The wound was sutured and therefore intended to heal as primary intention. The wound is red and inflamed with serosanguinous drainage, and is four days old, which is the inflammatory phase. In the proliferative phase, the skin is still reddened but is no longer greatly inflamed. The maturation phase is characterized by a scar that continues to grow stronger with tissue growth. Secondary intention healing occurs when the wound is left open to heal rather than being sutured or approximated.

Answer to Question 2

2
Rationale 1: The nurse can observe this data, so it is objective data.