A nurse is caring for a client with a stage 2 pressure injury on the coccyx who is at risk for additional pressure injuries. Which nursing intervention is appropriate when caring for this client?

Question

Quizplus · Accepted Answer

A)The nurse should avoid placing the client in the side-lying position because this position places increased pressure on the bony prominence of the greater trochanter. Also, the nurse should maintain the head of the bed at the lowest degree of elevation consistent with the client's medical condition and other restrictions. In addition, the nurse should clean the client's pressure injury at every dressing change, not as needed. Hydrogen peroxide should never be used on the wound bed due to the tissue damage it promotes.
B)The nurse should avoid placing the client in the side-lying position because this position places increased pressure on the bony prominence of the greater trochanter. Also, the nurse should maintain the head of the bed at the lowest degree of elevation consistent with the client's medical condition and other restrictions. In addition, the nurse should clean the client's pressure injury at every dressing change, not as needed. Hydrogen peroxide should never be used on the wound bed due to the tissue damage it promotes.
C)The nurse should avoid placing the client in the side-lying position because this position places increased pressure on the bony prominence of the greater trochanter. Also, the nurse should maintain the head of the bed at the lowest degree of elevation consistent with the client's medical condition and other restrictions. In addition, the nurse should clean the client's pressure injury at every dressing change, not as needed. Hydrogen peroxide should never be used on the wound bed due to the tissue damage it promotes.
D)The nurse should avoid placing the client in the side-lying position because this position places increased pressure on the bony prominence of the greater trochanter. Also, the nurse should maintain the head of the bed at the lowest degree of elevation consistent with the client's medical condition and other restrictions. In addition, the nurse should clean the client's pressure injury at every dressing change, not as needed. Hydrogen peroxide should never be used on the wound bed due to the tissue damage it promotes.

A Nurse Is Caring for a Client with a Stage