Question

The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take?

a. Ask the nursing assistive personnel if the wound looks better.
b. Document the progress of wound healing as "better" in the 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.

Answer 1

The nurse's priority action for wound evaluation is to measure the wound and look for signs of infection such as redness, swelling, or drainage (option C).

Step-by-step explanation:

The priority action the nurse will take when caring for a patient with an open wound to evaluate the progress of wound healing is to measure the wound and observe for redness, swelling, or drainage (option C).

These observations help to assess whether the wound is healing properly or if there is an infection that requires additional treatment. It is not advised to leave the dressing off for easier access as this could expose the wound to potential contaminants and delay healing.

Additionally, while input from nursing assistive personnel can be valuable, it is essential for the nurse to personally evaluate the wound for a professional assessment of healing.

Answer 2

The priority action for the nurse in evaluating the progress of wound healing is Measure the wound and observe for redness, swelling, or drainage.Thus the option c. Measure the wound and observe for redness, swelling, or drainage is correct.

Step-by-step explanation:

Measuring the wound and observing for signs of inflammation, such as redness, swelling, or drainage, is a crucial and systematic approach to evaluating the progress of wound healing. This method provides objective data that can be accurately documented in the patient's chart and serves as a baseline for future comparisons.

It allows the nurse to track changes in wound size, appearance, and any signs of infection, enabling timely interventions if needed.Option (a) relies on subjective judgment and does not provide measurable data for assessment. Option (b) lacks specificity and precision, as describing the progress as "better" does not convey the detailed information necessary for comprehensive wound evaluation. Option (d) poses a risk by leaving the wound undressed, which may compromise infection control and impede proper wound healing.

Therefore, measuring the wound and assessing for specific indicators of healing or complications is the most appropriate and effective action for the nurse in this context.

Thus the option c. Measure the wound and observe for redness, swelling, or drainage is correct.