During morning care in a skilled nursing facility, the student nurse notices that the patient who is at risk for impaired skin integrity has developed a small open area on his sacrum. To best address this situation, the student would first:
A) position the patient to lie on his side, document it, and inform the head nurse.
B) position the patient on his side and encourage him to massage around the area.
C) report to the physician so that the nursing care plan can be revised.
D) tell the nursing assistant to change the patient's position every 2 hours.

Question

Quizplus · Accepted Answer

This change in the patient's position with documentation is the initial intervention. The discovery of an open lesion requires a change in the nursing plan.

During Morning Care in a Skilled Nursing Facility, the Student