The nurse is caring for a patient with a healing Stage III ...

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The nurse is caring for a patient with a healing Stage III pressure ulcer. The wound is clean and granulating. Which health care provider's order will the nurse question?
 
  a. Use a low-air-loss therapy unit.
  b. Irrigate with Dakin's solution.
  c. Apply a hydrogel dressing.
  d. Consult a dietitian.

Question 2

The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient?
 
  a. Low-air-loss
  b. Air-fluidized
  c. Lateral rotation
  d. Standard mattress

[cuttiesgirl16]

Answer to Question 1

ANS: B
Clean pressure ulcers with noncytotoxic cleansers such as normal saline, which will not kill fibroblasts and healing tissue. Cytotoxic cleansers such as Dakin's solution, acetic acid, povidone-iodine, and hydrogen peroxide can hinder the healing process and should not be utilized on clean granulating wounds. Consulting a dietitian for the nutritional needs of the patient, utilizing a low-air-loss therapy unit to decrease pressure, and applying hydrogel dressings to provide a moist environment for healing are all orders that would be appropriate.

Answer to Question 2

ANS: B
For a patient with newly flapped or grafted surgical sites, the air-fluidized bed will be the best choice; this uses air and fluid support to provide pressure redistribution via a fluid-like medium created by forcing air through beads as characterized by immersion and envelopment. A low-air-loss bed is utilized for prevention or treatment of skin breakdown by preventing buildup of moisture and skin breakdown through the use of airflow. A standard mattress is utilized for an individual who does not have actual or potential altered or impaired skin integrity. Lateral rotation is used for treatment and prevention of pulmonary, venous stasis and urinary complications associated with mobility.