A client has a stage 2 decubitus ulcer on the left foot. The nurse is completing discharge instructions for the client and spouse about care of the wound and skin assessment
The nurse concludes that the client has understood teaching if the client states which of the following? 1. "I will soak in the tub in hot water for 30 minutes every day."
2. "I will call the doctor if I notice a blister anywhere on my body."
3. "I will call the doctor if I notice a blister on a pressure point."
4. "I will call the doctor if I feel pain or see redness over a pressure point."
4
Rationale: The nurse would want the client to understand that the time to call the doctor is before a pressure ulcer forms. Noticing tissue pain or redness would be an early sign of a potential ulcer. Hot-water baths will contribute to skin breakdown. A blister on an area of the body is not necessarily a reason to notify the doctor. A blister on a bony prominence is already a stage 2 decubitus, and the client needs to notify the doctor at stage 1 or before.
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