The nurse assesses a bed-bound resident, a reddened area over the ...

[sheilaspns]

The nurse assesses a bed-bound resident, a reddened area over the coccyx that does not blanch is discovered. Which is the best intervention to prevent further skin damage?
 
  a. Cover the site with a transparent film dressing.
  b. Apply warm compresses each shift.
  c. Turn the patient every 2 hours.
  d. Continue to monitor the area.

Question 2

The home health nurse is caring for a patient with polycythemia vera. Which focus is most important for the nurse to emphasize?
 
  a. Maintenance of high fluid intake
  b. Daily exercise to reduce weight
  c. Daily dose of anticoagulants
  d. Adequate intake of vitamin C

[alexanderhamilton]

Answer to Question 1

A
Since this appears to be a stage 1 pressure area, the transparent film ensures the proper amount of moisture is present for healing while allowing monitoring of the area. A warm compress is not warranted. This patient will need to be turned every hour. Monitoring of the area should continue but does not meet the immediate need.

Answer to Question 2

A
The major focus is maintaining a high fluid intake to keep the circulating fluid well hydrated.