Correct answer: A) The wound has a foul odor and purulent drainage.

Rationale: The wound with a foul odor and purulent drainage indicates an infection, which can delay healing and cause systemic complications, such as sepsis. The nurse should report this finding to the provider immediately and obtain a wound culture and sensitivity test.

Incorrect options:

B) The wound has a black, necrotic tissue in the center. - This indicates eschar, which is dead tissue that needs to be debrided to promote healing. However, this is not an urgent finding and can be addressed by the wound care team.

C) The wound has a red, granulating tissue at the edges. - This indicates healthy tissue formation and healing. This is a positive finding and does not need to be reported.

D) The wound has a yellow, sloughing tissue on the surface. - This indicates fibrin, which is a protein that forms during inflammation and can impede healing. The nurse should remove this tissue by irrigation or debridement, but this is not an urgent finding.

Rationale: The client with venous insufficiency has impaired venous return from the lower extremities, which causes edema, inflammation, and skin breakdown. The nurse should instruct the client to apply compression stockings or bandages to improve blood flow and reduce swelling; avoid crossing the legs or wearing tight-fitting clothing that can constrict blood vessels; and keep the leg elevated when sitting or lying down to facilitate venous return.

Correct answer: D) Gangrene or necrosis of the toes.

Rationale: The client with arterial insufficiency has reduced arterial blood supply to

the lower extremities, which causes ischemia, pain, and tissue damage. Gangrene or necrosis of

the toes indicates severe tissue death that can lead to amputation if not treated promptly. The nurse should report this finding to the provider immediately and monitor for signs of infection or sepsis.

Incorrect options:

A) Absent or diminished pedal pulses. - This is an expected finding in clients with arterial insufficiency, as the blood flow to the lower extremities is compromised. The nurse should document this finding and compare it with the baseline and previous assessments.

B) Cold, pale, or cyanotic skin color. - This is an expected finding in clients with arterial insufficiency, as the skin does not receive adequate oxygen and nutrients from the blood. The nurse should document this finding and monitor for changes in skin temperature and color.

C) Loss of hair growth on the lower leg. - This is an expected finding in clients with arterial insufficiency, as the hair follicles do not receive adequate oxygen and nutrients from the blood. The nurse should document this finding and educate the client about proper foot care.