A nurse classifies a pressure ulcer according to the type of tissue in the wound bed. What does it indicate if the wound bed has granulation in it?
a. Wound needs debridement
b. The presence of significant infection
c. Colonization by bacteria
d. Movement toward healing
D
The presence of granulation tissue signifies a movement toward wound healing. Black tissue is necrotic tissue. A wound with a high percentage of black tissue will require debridement. Yellow tissue or slough tissue indicates the presence of infection or colonization.
You might also like to view...
A home health nurse makes a home visit to a 90-year-old patient who has cardiovascular disease. During the visit the patient asks the nurse, "Can you see the little green bugs that have been singing to me?"
The patient is also exhibiting signs of confusion and agitation. What should the home health nurse do? A) Have the patient's home care increased B) Have a family member check in on the patient in the evening C) Have the patient see his physician D) Refer the patient to an adult day program
List the five most common conditions in which pressure ulcers develop.
What will be an ideal response?
Jessica Tennesaw struggles with anxiety but she wants the least addictive prescriptive medication as possible, so her doctor prescribed _______.
a. amobarbital b. chlordiazepoxide c. pentobarbital d. tapentadol
What is a growing health concern for middle adults?
a. Menopause b. Obesity c. Nesting d. Sexually transmitted infections