Author Question: A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for ... (Read 60 times)

Chelseaamend · **on:** Jun 25, 2018

A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage, what instructions are most important for the nurse to teach the mother?

a. Change the patient's bedding frequently.
b. Use a hydrocolloid dressing over the ulcer.
c. Record the size and appearance of the ulcer weekly.
d. Change the patient's position at least every 2 hours.

Question 2

The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer?

a. Soak the old dressings with sterile saline 30 minutes before removing them.
b. Pour sterile saline onto the new dry dressings after the wound has been packed.
c. Apply antimicrobial ointment before repacking the wound with moist dressings.
d. Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.

Christopher · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: D
The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other interventions may also be included in family teaching, but the most important instruction is to change the patient's position at least every 2 hours.

Answer to Question 2

ANS: D
Mechanical debridement with wet-to-dry dressings is painful, and patients should receive pain medications before the dressing change begins. The new dressings are moistened with saline before being applied to the wound. Soaking the old dressings before removing them will eliminate the wound debridement that is the purpose of this type of dressing. Application of antimicrobial ointments is not indicated for a wet-to-dry dressing.