Author Question: A nurse is caring for a client with a Stage II pressure ulcer on the coccyx who is at risk for ... (Read 138 times)

JMatthes · **on:** Jun 25, 2018

A nurse is caring for a client with a Stage II pressure ulcer on the coccyx who is at risk for additional pressure ulcers. Which nursing intervention is appropriate while caring for this client?

A) Clean the pressure ulcer as needed.
B) Use hydrogen peroxide as chemical debridement of wound bed as needed.
C) Maintain the head of the client's bed at 30 .
D) Avoid placing the client in the side-lying position.

Question 2

A client has a pressure ulcer on the medial malleolus. The client's skin is intact with purple discoloration and a blood-filled blister. When documenting this finding, which terminology is appropriate for the nurse to use?

A) Partial-thickness loss of dermis
B) Non-blanchable erythema
C) Suspected deep tissue injury
D) Full-thickness tissue loss

nekcihc358 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Answer: D

The nurse should avoid placing the client in the side-lying position because this position places increased pressure on the bony prominence of the greater trochanter. Also, the nurse should maintain the head of the bed at the lowest degree of elevation consistent with the client's medical condition and other restrictions.
The nurse should clean the client's pressure ulcer at every dressing change, not as needed. Hydrogen peroxide should never be used on the wound bed due to the tissue damage it promotes.

Answer to Question 2

Answer: C

A suspected deep tissue injury manifests as intact skin with purple discoloration or a blood-filled blister. Non-blanchable erythema refers to a Stage I ulcer. Partial-thickness loss of dermis refers to a Stage II ulcer. Full-thickness tissue loss refers to Stage III, IV, and unstageable ulcers.