The nurse is caring for a patient with a large wound on the right hip. What nursing measure is the most essential for the patient?
1. Keep the patient on continuous bed rest.
2. Encourage the patient to sit up in a chair as much as possible through the day.
3. Turn the patient from side to side every 2 hours.
4. Keep the patient's weight off the right side.
4
Rationale 1: Unless a compromising factor exists, a large hip wound would not require complete bed rest.
Rationale 2: Prolonged chair sitting can be detrimental to wound healing, depending on where pressure is applied relative to the wound.
Rationale 3: Turning the patient from side to side is inappropriate; the patient would be lying on the wound half the time, creating pressure that would diminish the blood supply.
Rationale 4: Keeping pressure off the right hip is the essential nursing measure because pressure would decrease blood flow to the area. Blood flow is needed to get oxygen and nutrients to the area and heal the wound.
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