An elderly client is admitted for a hip fracture. During the postoperative recovery, the nurse notices a stage I pressure ulcer forming on the client's sacrum. To reduce the progression of this stage of ulcer, the nurse would:
1. Maintain the head of the bed at 45° angle.
2. Apply a dry dressing to pressure ulcer.
3. Maintain the head of the bed at 30° angle positioned on the right or left side.
4. Apply a heat lamp to the area to increase circulation.
3. Maintain the head of the bed at 30° angle positioned on the right or left side.
Rationale:
Keeping the head of the bed at an angle of 30° or less decreases pressure on the sacrum. Dry dressings are not indicated with this stage pressure wound. Heat lamp is a method no longer used as it does not provide therapeutic benefit.
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