A client requests a small inflated doughnut-style device to sit ...

[wrbasek0]

A client requests a small inflated doughnut-style device to sit on to relieve pressure. Which response by the nurse is most appropriate?
 
  A) I will need to get an order from the physician.
  B) Using the doughnut can cause skin breakdown.
  C) You will need to wait until discharge and use this at home.
  D) I will obtain the device for you.

Question 2

The nurse has established as an expected outcome that a client will demonstrate healing of a stage II pressure ulcer over the coccyx. Which finding indicates that the client failed to achieve this outcome?
 
  A) The rubber doughnut pressure relief device was not delivered by central supply.
  B) The client's serum albumin increased over the last month.
  C) A right side-back-left side-back turning schedule was utilized.
  D) Nurses did not document disinfection of the wound with alcohol with each dressing change.

[shewald78]

Answer to Question 1

Answer: B

The use of a doughnut-style device applies pressure and results in tissue anoxia. The client may indeed feel that pressure is lessened, but this is due to the loss of sensation. The use of the device should be avoided whether at the hospital or at home.

Answer to Question 2

Answer: C

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 side-back-left side-back turning schedule. This schedule places the client on the back for 50 of the time. The schedule should be right side-back-left side-right side. A rubber doughnut-style device should not be used, so the fact that it was not delivered did not indicate failure to meet the outcome. An increase in serum albumin is a good finding and would increase, not decrease, wound healing. The use of alcohol interrupts healing, so it is good that nurses did not document its use.

[wrbasek0]

Excellent

[epscape]

TYSM