Correct answer: B) The wound has a yellowish-green drainage.

Rationale: The wound has a yellowish-green drainage, which indicates infection and possible necrosis of the wound tissue. This finding should be reported to the wound care specialist for further evaluation and treatment.

Incorrect options:

A) The wound has a foul odor. - This is not a reportable finding, as foul odor may be present in some wounds without infection, especially if the wound is colonized by anaerobic bacteria. However, the nurse should monitor the wound for other signs of infection, such as increased pain, redness, swelling, or fever.

C) The wound has a granulation tissue in the base. - This is not a reportable finding, as granulation tissue is a sign of healing and indicates that new blood vessels and connective tissue are forming in the wound bed.

D) The wound has a partial-thickness skin loss. - This is not a reportable finding, as partial-thickness skin loss is consistent with the definition of a pressure ulcer, which is a localized injury to the skin and/or underlying tissue due to pressure or shear.

Correct answer: A) Apply sterile saline to moisten the foam dressing before removal.

Rationale: The nurse should apply sterile saline to moisten the foam dressing before removal, as this helps to prevent trauma and bleeding from adherent dressing. The nurse should also wear sterile gloves and use aseptic technique when changing the dressing.

Incorrect options:

B) Cut the foam dressing to fit loosely into the wound cavity. - This is an incorrect action, as the foam dressing should be cut to fit snugly into the wound cavity, leaving no gaps or spaces between the foam and the wound edges. This ensures optimal contact and negative pressure distribution within the wound.

C) Secure the transparent film dressing with tape around the edges. - This is an incorrect action, as the transparent film dressing should be secured with an adhesive drape that covers at least 3 cm beyond the edges of the film. This prevents air leaks and maintains negative pressure within the wound.

D) Disconnect the suction tubing from the foam dressing before turning off the device. - This is an incorrect action, as the suction tubing should be disconnected from the device before removing the foam dressing from the wound. This prevents accidental suction of air or fluid into the tubing or device.

Correct answer: D) The client has increased granulation tissue in the ulcer.

Rationale: The client has increased granulation tissue in

the ulcer, which indicates that HBOT has been effective in enhancing wound healing. HBOT delivers 100% oxygen at high pressure to increase oxygen delivery and diffusion to hypoxic tissues, stimulating angiogenesis, collagen synthesis, and fibroblast proliferation.

Incorrect options:

A) The client reports reduced pain in the affected leg. - This is not an outcome that indicates HBOT effectiveness, as pain reduction may be due to other factors, such as analgesics, compression therapy, or elevation of the leg. Pain is also not a reliable indicator of wound healing, as some wounds may heal without pain or have persistent pain despite healing.

B) The client has increased oxygen saturation in the blood. - This is not an outcome that indicates HBOT effectiveness, as oxygen saturation in the blood reflects systemic oxygenation and does not necessarily correlate with tissue oxygenation. Oxygen saturation may also vary depending on factors such as hemoglobin level, cardiac output, or ventilation-perfusion mismatch.

C) The client has decreased edema in the affected leg. - This is not an outcome that indicates HBOT effectiveness, as edema reduction may be due to other factors, such as compression therapy, diuretics, or elevation of

the leg. Edema is also not a reliable indicator of wound healing, as some wounds may heal with edema or have persistent edema despite healing.