The nurse is caring for a patient who is admitted to the medical unit for the treatment of a venous ulcer in the area of her lateral malleolus that has been unresponsive to treatment
What is the nurse most likely to find during an assessment of this patient's wound?
A) Hemorrhage
B) Heavy exudate
C) Deep wound bed
D) Pale-colored wound bed
Ans: B
Feedback:
Venous ulcerations in the area of the medial or lateral malleolus (gaiter area) are typically large, superficial, and highly exudative. Venous hypertension causes extravasation of blood, which discolors the area of the wound bed. Bleeding is not normally present.
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