Author Question: The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient ... (Read 38 times)

biggirl4568 · **on:** Jul 22, 2018

The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed.

How should the nurse document this ulcer in the patient's medical record?
a. Stage I pressure ulcer
b. Healing Stage II pressure ulcer
c. Healing Stage III pressure ulcer
d. Stage III pressure ulcer

Question 2

A nurse is preparing a bowel training program for a patient. Which actions will the nurse take? (Select all that apply.)

a. Record times when the patient is incontinent.
b. Help the patient to the toilet at the designated time.
c. Lean backward on the hips while sitting on the toilet.
d. Maintain normal exercise within the patient's physical ability.
e. Apply pressure with hands over the abdomen, and strain while pushing.
f. Choose a time based on the patient's pattern to initiate defecation-control measures.

nanny · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: C
When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is labeled with the words healing stage or healing Stage III pressure ulcer. Once an ulcer has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a Stage III, and it cannot return to a previous stage such as Stage I or II. This ulcer is healing, so it is no longer labeled a Stage III.

Answer to Question 2

ANS: A, B, D, F
A successful program includes the following: Assessing the normal elimination pattern and recording times when the patient is incontinent. Choosing a time based on the patient's pattern to initiate defecation-control measures. Maintaining normal exercise within the patient's physical ability. Helping the patient to the toilet at the designated time. Offering a hot drink (hot tea) or fruit juice (prune juice) (or whatever fluids normally stimulate peristalsis for the patient) before the defecation time. Instructing the patient to lean forward at the hips while sitting on the toilet, apply manual pressure with the hands over the abdomen, and bear down but do not strain to stimulate colon emptying.