The nurse is assessing a client’s pressure ulcer. To determine the dep

The nurse is assessing a client’s pressure ulcer. To determine the depth of the ulcer, the nurse should take which action?

1. Measure the width.
2. Measure the length.
3. Insert a sterile swab into the deepest part of the wound.
4. Identify where on the face of a clock the ulcer is located.

ANSWER

Correct Answer: 3
Rationale 1: Measuring the width of the wound does not provide the depth of the ulcer.
Rationale 2: Measuring the length of the wound does not provide the depth of the ulcer.
Rationale 3: To measure the depth of a wound, the nurse should insert a sterile swab into the deepest part of the wound and then measure the length of the swab that was inserted.
Rationale 4: Identifying locations on the face of a clock determines the presence of undermining or sinus tracts.