A quadriplegic patient who was admitted for pneumonia was found to have a stage III pressure ulcer. A nurse explains to the patient's mother that she will know that the pressure ulcer is in the reconstruction phase of healing when
1. A scab has formed over the wound.
2. Pink or red tissue can be seen in the wound.
3. The wound becomes warm to the touch.
4. A healing ridge has developed beneath the wound.
Question 2
A nurse determines that the best way to clean a long incision that is sutured or stapled closed with approximated edges is to
1. Use antiseptic swabs and clean from the inferior end of the incision to the superior end.
2. Use antiseptic swabs and clean around the wound in a circular manner.
3. Use sterile antiseptic swabs or cotton balls and forceps, and clean from the superior end of the incision to the inferior end.
4. Use one cotton ball to make a circular sweep and then dispose of the cotton ball.
stage II pressure ulcer
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