Author Question: The nurse is planning care for her patient who has a stage II pressure ulcer. Care should include ... (Read 95 times)

rlane42 · **on:** Jul 24, 2018

The nurse is planning care for her patient who has a stage II pressure ulcer. Care should include which of the following? (Select all that apply.)

a. A heat lamp to dry the wound
b. Application of topical antibiotics
c. Nutritional assessment
d. Maintaining moisture in the wound

Question 2

To assist the patient to a sitting position on the side of the bed, what should the nurse do first?

a. Raise the height of the bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient's legs over the side of the bed.

fauacakatahaias · **Reply #1 on:** Jul 24, 2018

Answer to Question 1

B, C, D
The treatment plan for a patient with a pressure ulcer must include elimination or reduction of the factors that have caused the pressure ulcer. A moist wound environment supports the growth of new tissue. If the wound is not free of necrotic tissue, you need to choose topical wound care that will cleanse the wound bed of devitalized tissue. Treat infection both systematically and topically. Wound healing in a patient with a pressure ulcer progresses if the patient has adequate nutritional status as well as control over preexisting conditions such as diabetes and cardiovascular and pulmonary disease.

Answer to Question 2

B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient and the nurse to raise the patient to a sitting position.
The bed should be in the low position. The patient is turned to face the nurse after the head of the bed is raised 30 degrees. The patient's legs are positioned over the edge of the bed after the head of the bed is raised and the patient is turned to face the nurse.