The nurse has established an expected outcome that the client ...

[bobbysung]

The nurse has established an expected outcome that the client will demonstrate healing of a stage II pressure ulcer over the coccyx. Which finding, discovered by the nurse during evaluation, might be implicated in the failure to achieve this outcome?
 
  1. The rubber doughnut pressure relief device was not delivered by central supply.
  2. The client's serum albumin increased over the last month.
  3. Nurses did not document disinfection of the wound with alcohol with each dressing change.
  4. Unlicensed assistive personnel (UAP) followed a right sidebackleft sideback turning schedule.

Question 2

Upon assessing a pressure ulcer, the nurse notes the presence of red, yellow, and black tissue. Using the RYB color code, which wound care should the nurse plan?
 
  1. Red
  2. Yellow
  3. Black
  4. A combination of all three

[hanadaa]

Answer to Question 1

Correct Answer: 4
Rationale 1: A rubber doughnut should not be used, so the fact that it was not delivered did not cause failure to meet the outcome.
Rationale 2: An increase in serum albumin is a good finding and would increase wound healing, not decrease wound healing.
Rationale 3: The use of alcohol interrupts healing, so it is good that nurses did not document its use.
Rationale 4: Because this expected outcome was not met, the nurse looks for problems in the provision of care or changes in the client's condition. Of the options listed, the only one that would result in poor healing is the right sidebackleft sideback turning schedule. This schedule places the client on the back for 50 of the time. The schedule should be right sidebackleft sideright side.

Answer to Question 2

Correct Answer: 3
Rationale: When using the RYB color code to guide wound care for a wound that contains more than one of the colors, the nurse plans care for the most serious color, in this case black.

[bobbysung]

TYSM

[sultansheikh]

Excellent