Author Question: The nurse is evaluating whether a patient's turning schedule was effective in preventing the ... (Read 61 times)

berenicecastro · **on:** Jul 22, 2018

The nurse is evaluating whether a patient's turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule?

a. Staff documentation of turning the patient every 2 hours
b. Presence of redness only on the heels of the patient
c. Patient's eating 100 of all meals
d. Absence of skin breakdown

Question 2

A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?

a. Reassess the patient and situation.
b. Revise the turning schedule to increase the frequency.
c. Delegate turning to the nursing assistive personnel.
d. Apply medication to the area of skin that is broken down.

britb2u · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: D
To determine whether a turning schedule is successful, the nurse needs to assess for the presence of skin breakdown. Redness on any part of the body, including only the patient's heels, indicates that the turning schedule was not successful. Documentation of interventions does not evaluate whether patient outcomes were met. Eating 100 of meals does not evaluate the effectiveness of a turning schedule.

Answer to Question 2

ANS: A
If a nursing diagnosis is unresolved or if you determine that a new problem has perhaps developed, reassessment is necessary. A complete reassessment of patient factors relating to an existing nursing diagnosis and etiology is necessary when modifying a plan. The nurse must assess before revising, delegating and applying medication. The breakdown may be a result of inadequate nutritional intake and medication cannot be applied unless there is an order.