Wounds and Pressure Ulcers
Wounds and Pressure Ulcers ( 15 Questions)
A nurse is assessing a patient with a pressure ulcer. Select all the appropriate actions the nurse should take during the assessment.
Measuring the wound size and depth is an essential action during the assessment of a pressure ulcer.
It helps in determining the severity of the ulcer, tracking its progress, and planning appropriate wound care interventions.
Administering pain management as needed is not specifically related to the assessment phase but is an important aspect of pressure ulcer management overall.
Pain management is crucial to ensure the patient's comfort and adherence to the treatment plan, but it is not a direct assessment action.
Checking vital signs for signs of infection is an appropriate action during the assessment of a patient with a pressure ulcer.
Fever and other vital sign abnormalities may indicate the presence of an infection in the wound, which requires immediate attention.
Assessing the patient's nutritional status is a critical part of the assessment process for a patient with a pressure ulcer.
Malnutrition can delay wound healing, so assessing nutritional needs and addressing deficiencies is essential.
Ensuring proper mobility to prevent pressure on vulnerable areas is an appropriate action during the assessment.
Assessing the patient's mobility status helps in identifying areas at risk for pressure ulcers and developing preventive strategies.
However, this action may also extend beyond the assessment phase and involve ongoing care.
Choice A rationale:
Measuring the wound size and depth is an essential action during the assessment of a pressure ulcer.
It helps in determining the severity of the ulcer, tracking its progress, and planning appropriate wound care interventions.
Choice B rationale:
Administering pain management as needed is not specifically related to the assessment phase but is an important aspect of pressure ulcer management overall.
Pain management is crucial to ensure the patient's comfort and adherence to the treatment plan, but it is not a direct assessment action.
Choice C rationale:
Checking vital signs for signs of infection is an appropriate action during the assessment of a patient with a pressure ulcer.
Fever and other vital sign abnormalities may indicate the presence of an infection in the wound, which requires immediate attention.
Choice D rationale:
Assessing the patient's nutritional status is a critical part of the assessment process for a patient with a pressure ulcer.
Malnutrition can delay wound healing, so assessing nutritional needs and addressing deficiencies is essential.
Choice E rationale:
Ensuring proper mobility to prevent pressure on vulnerable areas is an appropriate action during the assessment.
Assessing the patient's mobility status helps in identifying areas at risk for pressure ulcers and developing preventive strategies.
However, this action may also extend beyond the assessment phase and involve ongoing care.