An 86-year-old resident struck her forearm on a table, causing a category I L-shaped skin tear 6 cm ? 2 cm. The nurse should: (Select all that apply.)
a. clean the tear with alcohol.
b. approximate the edges of the tear.
c. secure the skin flap with Steri-Strips.
d. cover with a nonadherent dressing.
e. assess closely for 5 days for signs of in-fection.
B, C, D, E
Alcohol would act as an irritant to the skin tear and should be avoided. Cleansing with normal saline is recommended. The remaining options are appropriate for the management of the skin tear.
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