Author Question: A patient is admitted to the hospital with a pressure ulcer on the sacrum. The wound is open with ... (Read 51 times)

HudsonKB16 · **on:** Jul 22, 2018

A patient is admitted to the hospital with a pressure ulcer on the sacrum. The wound is open with exposed bone. The nurse should document this pressure ulcer at what stage?

a. Stage I
b. Stage II
c. Stage III
d. Stage IV

Question 2

A patient is confused and has been restrained to prevent injury. Which of the following is a priority as the nurse plans care for the shift?

a. Calling the physician for an order for a chemical restraint
b. Applying the most restrictive restraint to prevent injury
c. Removing the restraints on the patient at least every 2 hours
d. Checking on the restrained patient last

nital · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

D
Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling
Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence
Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister
Stage III: Full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling

Answer to Question 2

C
Assess proper placement of restraint, skin integrity, pulses, temperature, color, and sensation of the restrained body part. Remove restraints at least every 2 hours or more frequently as determined by agency policy. If patient is violent or noncompliant, remove one restraint at a time and/or have other staff present while removing restraints. Chemical restraints are medications, such as anxiolytics and sedatives, used to manage a patient's behavior and are not a standard treatment for a patient's condition. Always attempt restraint alternatives before using a restraint. If a restraint is needed, always use the least restrictive device. Checking restrained patients last is not appropriate. Legislation emphasizes reducing the use of restraints. The Joint Commission and Centers for Medicare and Medicaid Services enforce standards for the safe use of restraint devices.