A client has a yellow wound with purulent drainage. The nurse ...

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A client has a yellow wound with purulent drainage. The nurse identifies what type of wound care as appropriate for this client's wound?
 
  1. Cover it with transparent film.
  2. Damp-to-damp normal saline dressing.
  3. Cover it with a dry dressing.
  4. Irrigating the wound.
  5. Apply impregnated hydrogel.

Question 2

The nurse is assessing a client's pressure ulcer. To determine the depth of the ulcer, the nurse should:
 
  1. Measure the width.
  2. Measure the length.
  3. Insert a sterile swab into the deepest part of the wound.
  4. Identify where on the face of a clock the ulcer is located.

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Answer to Question 1

Correct Answer: 2,4,5
Rationale 1: Covering with a transparent film is not appropriate for a yellow wound.
Rationale 2: Damp-to-damp normal saline dressing will remove nonviable tissue from the wound, and is appropriate for a yellow wound.
Rationale 3: Covering with a dry dressing is not appropriate for a yellow wound.
Rationale 4: Irrigating the wound is appropriate for a yellow wound.
Rationale 5: Applying impregnated hydrogel is appropriate for a yellow wound.

Answer to Question 2

Correct Answer: 3
Rationale 1: Measuring the width of the wound does not provide the depth of the ulcer.
Rationale 2: Measuring the length of the wound does not provide the depth of the ulcer.
Rationale 3: To measure the depth of a wound, the nurse should insert a sterile swab into the deepest part of the wound and then measure the length of the swab that was inserted.
Rationale 4: Identifying locations on the face of a clock determines the presence of undermining or sinus tracts.

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TYSM

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