A patient has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient?
a. Transparent film dressing
b. Sheet hydrogel
c. Frequent turn schedule
d. Enzymatic debridement
C
The patient should be placed on a turn schedule to relieve the pressure. If pressure is not relieved, the wound will worsen. A stage I wound is not open, so a dressing is not warranted. Enzymatic debridement is used to remove slough or eschar in an open wound. A transparent film dressing would protect the area. However, the primary treatment is to relieve the source of pressure.
You might also like to view...
A critically ill patient is receiving acetaminophen (Tylenol) in combination with opioids for pain management. Under what circumstances would the nurse question the use of acetaminophen?
A) Normal liver function tests B) Low platelet levels C) Relative hypothermia D) Reduced pain levels
When evaluating the hydration status, the nurse observes tenting of the skin on the back of the 87-year-old client's hand when testing the skin turgor. What is the nurse's best action?
A. Notify the physician. B. Examine dependent body areas. C. Assess turgor on the client's forehead. D. Document the finding as the only action.
Clients in which of the following age ranges would be likely to receive the least amount of touch?
a. 5 to 15 b. 20 to 35 c. 45 to 60 d. 70 to 85
Low beds are commonly used in the care of patients who are at risk of
A. pressure ulcers. B. contractures. C. falls. D. dehydration.