Author Question: The nurse knows the most appropriate goal for a patient with a stage III pressure ulcer who has a ... (Read 52 times)

penguins · **on:** Jul 23, 2018

The nurse knows the most appropriate goal for a patient with a stage III pressure ulcer who has a nursing diagnosis of Impaired skin integrity is:

a. the wound will be completely healed in 72 hours.
b. the wound will show signs of healing within 2 weeks.
c. the patient will develop no new pressure ulcers.
d. the patient will ambulate twice a day.

Question 2

The nurse is delegating care of a patient with a chronic nonsterile wound to a UAP. The delegation is inappropriate if:

a. the nurse asks the UAP to assess the wound.
b. the nurse asks the UAP to report increased wound drainage.
c. the nurse asks the UAP to observe changes in dietary intake.
d. the nurse asks the UAP to change the dressing.

medine · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: B
A stage III pressure ulcer is a more extensive wound and will take time to heal, so the most appropriate goal will be to show signs of healing in 2 weeks. It will not heal in 72 hours. The goal of no new pressure ulcers is good, but not the most appropriate, and ambulating twice a day is more of an intervention.

Answer to Question 2

ANS: A
Assessment and evaluation of a patient's skin and wounds, and the effectiveness of the treatment plan, are a nurse's responsibility and cannot be delegated to unlicensed assistive personnel (UAP). UAP should report to the nurse any changes in skin condition or integrity; elevation in temperature; complaints of pain; increased wound drainage or incontinence; and observed changes in dietary intake. Some dressing changes can be performed by UAP in some situations.