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