A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment findings should prompt the nurse to request a referral from the wound care nurse?

A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment findings should prompt the nurse to request a referral from the wound care nurse?




a) A wound measuring 9 cm × 5 cm × 0.5 cm with granulation tissue
b) A wound measuring 1 cm × 2 cm × 0.5 cm with a red, moist wound bed
c) A wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearance
d) A wound measuring 2 cm × 2 cm × 0.5 cm with granulation tissue



Answer: C


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