Upon assessment a nurse discovers that a patient has erythema. Which actions will the nurse take? (Select all that apply.)
a. Consult a dietitian.
b. Increase fiber in the diet.
c. Place on chest physiotherapy.
d. Increase frequency of turning.
e. Place on pressure-relieving mattress.
ANS: A, D, E
If skin shows areas of erythema and breakdown, increase the frequency of turning and repositioning; place the turning schedule above the patient's bed; implement other activities per agency skin care policy or protocol (e.g., assess more frequently, consult dietitian, place patient on pressure-relieving mattress). Increased fiber will help constipation. Chest physiotherapy is for respiratory complications.
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