When evaluating a client, a nurse observes an unexpected outcome of treatment when the surrounding skin of an ulcer becomes macerated. The nurse should:
A. Obtain a wound culture
B. Apply pressure-reducing devices
C. Use dressings with increased moisture absorption
D. Monitor the client for systemic signs and symptoms
C
C. Dressings that increase moisture absorption will result in dryer skin that is less macerated.
A. A wound culture is not indicated for macerated skin.
B. Pressure-reducing devices are not indicated for macerated skin.
D. Macerated skin is a local reaction; the client would not need systemic monitoring.
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