22.4 post test pressure ulcers
The nurse is caring for a client admitted with a pressure ulcer. Which data should the nurse document when assessing the pressure ulcer? (Select all that apply.)
Integrity of the surrounding tissue Color of the wound bed Stage of the ulcer Signs of infection
A client who is confined to bed is at risk for developing a pressure ulcer. What support surface should the nurse request for this client?
Kinetic bed
While assessing the skin of a surgical client, the nurse observes erythema to the left scapulae. What is the best action for the nurse to take before reassessing the skin to determine if the erythema is a pressure ulcer?
Repositioning the client
The charge nurse has just received the report for all clients on the unit. Which client should the nurse consider as being at risk for the development of pressure ulcers? (Select all that apply.)
The client who is 92 years old The client who has type 1 diabetes mellitus The client who is on bed rest The client who has a history of anorexia nervosa
The nurse is caring for a client with a pressure ulcer on the right elbow that is covered with eschar. The nurse should document this ulcer as being which stage?
Stage IV
The nurse is educating a student about alginate dressings. On what type of pressure ulcer is this type of dressing used? (Select all that apply.)
Stage IV without eschar Stage III Stage II