A standard care plan for impaired skin integrity has been implemented for a patient with a small sore on the sole of the left foot. What action should the nurse use to evaluate the effectiveness of the plan?
a. Monitor and record blood glucose levels daily.
b. Assess and document the wound condition daily.
c. Observe the patient's ability to change the dressing.
d. Assess the patient's understanding of preventive foot care.
ANS: B
Evaluation must address skin integrity—assessing and documenting wound condition is the only response that does this. A. Monitoring glucose levels evaluates diabetes control, not skin integrity. C. D. Assessing the patient's understanding or observing a dressing change evaluates the patient's knowledge, not skin integrity.
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