Author Question: The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ... (Read 122 times)

Themember4 · **on:** Jul 22, 2018

The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers.

The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage a. I.
b. II.
c. III.
d. IV.

Question 2

The nurse is caring for a preoperative patient. The nurse teaches the principles and demonstrates leg exercises for the patient. The patient is unable to perform leg exercises correctly. What is the nurse's best next step?

a. Assess for the presence of anxiety, pain, or fatigue.
b. Ask the patient why he does not want to do the exercises.
c. Encourage the patient to practice at a later date.
d. Assess the educational methods used to educate the patient.

cuttiesgirl16 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

A
Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. This allows visual inspection and monitoring. A transparent dressing could be used to protect the patient from shear but cannot be used in the presence of excessive moisture. A composite film, hydrocolloid, or hydrogel can be utilized on a clean stage II. A hydrocolloid, hydrogel covered with foam, calcium alginate, gauze, and growth factors can be utilized with a clean stage III. Hydrogel, calcium alginate, gauze, and growth factors can be utilized with a clean stage IV. An unstageable wound cover with eschar should utilize a dressing of adherent film or gauze with an ordered solution of enzymes. In rare cases when eschar is dry and intact, no dressing is used, but this is an unstaged ulcer.

Answer to Question 2

A
If the patient is unable to perform leg exercises after sound educational principles and demonstration are provided, the nurse should look for circumstances that may be impacting the patient's ability to learn. In this case, the patient can be anticipating the upcoming surgery and may be experiencing anxiety. The patient may also be in pain or may be fatigued; both of these can affect the ability to learn. Assessment of educational methods may be needed, but in this case, sound principles and demonstration are being utilized. Asking anyone why can cause defensiveness and may not help in attaining the answer. In this case, the patient really may want to participate and may not know why he is unable to learn. The nurse is aware that the patient is unable to do the exercises. Moving forward without ascertaining that learning has occurred will not help the patient in meeting goals.