The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?
a. Monitor the wound.
b. Document the wound.
c. Debride the wound.
d. Manage drainage from wound.
ANS: C
Debridement is the removal of nonviable necrotic (black) tissue. Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base for healing. A wound will not move through the phases of healing if the wound is infected. Documentation occurs after completion of skill. When treating a pressure ulcer, it is important to monitor and reassess the wound at least every 8 hours. Management of drainage will help keep the wound clean, but that is not the next step.
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A) Naturally acquired active immunity B) Artificially acquired active immunity C) Naturally acquired passive immunity D) Artificially acquired passive immunity
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