Author Question: A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How ... (Read 121 times)

Wadzanai · **on:** Jun 25, 2018

A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How would the nurse document this wound?

a. Red wound
b. Yellow wound
c. Full-thickness wound
d. Stage III pressure ulcer

Question 2

A patient's 4 3-cm leg wound has a 0.4 cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound?

a. Dry gauze dressing (Kerlix)
b. Nonadherent dressing (Xeroform)
c. Hydrocolloid dressing (DuoDerm)
d. Transparent film dressing (Tegaderm)

welcom1000 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
The description is consistent with a red wound. A stage III pressure ulcer would expose subcutaneous fat. A yellow wound would have creamy colored exudate. A full-thickness wound involves subcutaneous tissue, which is not indicated in the wound description.

Answer to Question 2

ANS: C
The wound requires debridement of the necrotic areas and absorption of the yellow-green slough. A hydrocolloid dressing such as DuoDerm would accomplish these goals. Transparent film dressings are used for red wounds or approximated surgical incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb wound drainage or debride the wound.