The nurse administers Accuzyme® ointment to the client's stage II pressure ulcer. Rank the nursing interventions in order
1. Apply the ointment up to wound edges.
2. Assess necrotic tissue in the wound bed.
3. Cover the wound bed with moist dressing.
4. Reposition client comfortably off wound.
2, 1, 3, 4
2. To administer an enzymatic ointment such as Accuzyme, the nurse assesses the wound to observe for necrotic tissue because the purpose of the ointment is to remove dead tissue; the nurse avoids applying enzymatic ointment to healthy tissue.
1. After proper cleansing, the nurse covers the wound with enzymatic ointment, being careful to avoid healthy tissue.
3. Enzymatic ointments require a moist environment to work properly so the nurse applies a moist dressing over the ointment-covered wound.
4. Finally, the nurse assists the client into a comfortable position that avoids applying pressure or friction to the site.
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The nurse is concerned that an older patient is experiencing sleep apnea. What did the nurse assess in this patient? Standard Text: Select all that apply
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