Certified Medical-Surgical Registered Nurse Practice Exam

What characteristic is most likely found during an assessment of a patient with venous ulceration?

1. Gangrene

2. Heavy exudate

3. Deep wound bed

4. Pale wound bed

The correct answer is: Heavy exudate

The characteristic most likely found during an assessment of a patient with venous ulceration is heavy exudate. Venous ulcers, which are often located on the lower legs, result from poor venous return and increased venous pressure. This condition leads to fluid accumulation and interstitial edema, ultimately causing the skin to break down and ulcerate. The heavy exudate is a direct result of the inflammatory process and the accumulation of excess fluid in the area. This fluid typically consists of a mix of serum, fibrin, and white blood cells, which appears as a serous or sometimes purulent discharge. The presence of heavy exudate can also be an indicator of the active inflammatory process associated with venous insufficiency. In contrast, gangrene is typically associated with arterial ulcers and would not be expected in venous ulceration, as it reflects tissue necrosis from a lack of blood supply. A deep wound bed is more characteristic of arterial ulcers, which tend to be deeper and have a more necrotic appearance. A pale wound bed is also not typical of venous ulcers, as these wounds generally present with a more reddish or dark pigmentation due to the surrounding fluid and inflammation.