Author Question: A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to ... (Read 64 times)

krzymel

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A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as?
 
  a. Stage I pressure ulcer, healing
  b. Stage II pressure ulcer, healing
  c. Stage III pressure ulcer, healing
  d. Stage IV pressure ulcer, healing

Question 2

Which of the following older adult patients needs to increase his daily fluid intake? One who typically drinks (assume three meals per day):
 
  a. 200 mL at each meal, plus 1,000 mL throughout the day
  b. 250 mL at each meal, plus 600 mL throughout the day
  c. 300 mL at each meal, plus 1,000 mL throughout the day
  d. 400 mL at each meal, plus 500 mL throughout the day



itsakadoozi

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Answer to Question 1

D
Reverse staging is not done because, as the ulcer heals with granulation tissue and becomes shallower, the lost muscle, subcutaneous fat, and dermis are not replaced. Pressure ulcers maintain their original staging classification throughout the healing process but are accompanied by the modifier healing.

Answer to Question 2

B
The fluid requirement is 1,500 to 2,000 mL per day. Drinking 250 mL  3 meals provides a 750 mL intake. Adding 600 mL totals only 1,350 mL per day. Drinking 200 mL per meal provides 600 mL, plus 1,000 mL totals 1,600, which is adequate. Drinking 300 mL per meal  3 = 900 mL; 900 + 1,000 is a total of 1,900 mL, which is within the acceptable range. Drinking 400 mL per meal  3  1,200 mL, plus 500 mL totals 1,700 mL, within the acceptable range.



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