The nurse has established as an expected outcome that a client will "demonstrate healing of a stage II pressure ulcer over the coccyx." Which finding indicates that the client failed to achieve this outcome?
A) The rubber doughnut pressure relief device was not delivered by central supply.
B) The client's serum albumin increased over the last month.
C) A right side-back-left side-back turning schedule was utilized.
D) Nurses did not document disinfection of the wound with alcohol with each dressing change.
Answer: C
Because this expected outcome was not met, the nurse looks for problems in the provision of care or changes in the client's condition. Of the options listed, the only one that would result in poor healing is the right side-back-left side-back turning schedule. This schedule places the client on the back for 50% of the time. The schedule should be right side-back-left side-right side. A rubber doughnut-style device should not be used, so the fact that it was not delivered did not indicate failure to meet the outcome. An increase in serum albumin is a good finding and would increase, not decrease, wound healing. The use of alcohol interrupts healing, so it is good that nurses did not document its use.
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