An older adult client is admitted to the medical-surgical unit for a hip fracture. During postoperative recovery, the nurse notices a stage I pressure ulcer forming on the client's sacrum
Which action by the nurse is appropriate to reduce the progression of this ulceration?
A) Maintain the head of the bed at 30 ° angle, with client positioned on the right or left side.
B) Apply a heat lamp to the area to increase circulation.
C) Apply a dry dressing to the pressure ulcer.
D) Maintain the head of the bed at 45 ° angle.
Answer: A
Keeping the head of the bed at an angle of 30 ° or less decreases pressure on the sacrum. An angle of 45 ° would be too severe and could exacerbate pressure ulcer formation on the sacrum. Dry dressings are not indicated with this stage of pressure wound. Heat lamp is a method no longer used because it does not provide therapeutic benefit.
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