What type of tissue in the wound bed indicates healthy healing?

A. A dressing helps protect the wound from contamination: Dressings act as a physical barrier against microorganisms, debris, and external trauma. Maintaining a protected environment reduces the risk of local infection and supports optimal healing conditions. This is a fundamental purpose of wound dressings.

B. The wound and the surrounding skin need to be cleaned with each dressing change: Cleansing removes exudate, necrotic debris, and surface bacteria that can delay healing. Cleaning the surrounding skin also prevents maceration and skin breakdown from drainage. Consistent cleansing supports accurate wound assessment.

C. A dressing is required for an open wound with extensive tissue loss: Open wounds with significant tissue loss require coverage to maintain moisture balance and protect exposed structures. Dressings support granulation tissue formation and reduce evaporative fluid loss. Leaving such wounds uncovered increases infection risk.

D. The dressing type should stay the same throughout the course of wound treatment: Dressing selection should change as the wound progresses through healing phases. Variations in exudate level, tissue type, and infection risk require different dressing properties. Ongoing reassessment guides appropriate modification.

E. The dressing should control drainage without fully drying out the wound bed: A moist wound environment promotes epithelialization and cellular migration. Dressings should absorb excess exudate while preventing desiccation of viable tissue. Proper moisture balance accelerates healing and reduces pain.

A. A client with an abnormal gait who takes an anticonvulsant medication: This client is at increased fall risk due to gait instability and potential medication side effects. However, if the client can request assistance and is cognitively intact, the immediate risk is lower than for clients with impaired judgment.

B. A client with lower extremity weakness and dementia: Dementia impairs judgment, awareness of limitations, and the ability to request help, while lower extremity weakness compromises mobility. This combination places the client at highest immediate risk for unassisted falls, making activation of the bed alarm a priority.

C. A client with visual impairment who calls for assistance when needed: While visual deficits increase fall risk, the client’s ability to recognize limitations and seek help mitigates immediate danger. The fall risk is present but less urgent than for a cognitively impaired client who may attempt to get out of bed unassisted.

D. A client with hypotension who uses a walker to ambulate: Hypotension may cause dizziness, increasing fall risk during ambulation. However, if the client waits for assistance and uses mobility aids appropriately, the risk of unassisted falls is lower than in a client with dementia and mobility weakness.