The nurse is caring for a patient who has an open wound. When evaluating the progress of wound healing, what is the nurse's priority action?
a. Ask the nursing assistive personnel if the wound looks better.
b. Document the progress of wound healing as "better" in the patient's chart.
c. Measure the wound and observe for redness, swelling, or drainage.
d. Leave the dressing off the wound for easier access and more frequent assessments.
C
The nurse performs evaluative measures, such as completing a wound assessment, to evaluate wound healing. Nurses do not delegate assessment to nursing assistive personnel. Documenting "better" is subjective and does not objectively describe the wound. Leaving the dressing off for the nurse's benefit of easier access is not a part of the evaluation process.
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