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brigittmarie brigittmarie
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6 years ago
A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?
 
  a. Reassess the patient and situation.
  b. Revise the turning schedule to increase the frequency.
  c. Delegate turning to the nursing assistive personnel.
  d. Apply medication to the area of skin that is broken down.
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wrote...
6 years ago
ANS: A
If a nursing diagnosis is unresolved or if you determine that a new problem has perhaps developed, reassessment is necessary. A complete reassessment of patient factors relating to an existing nursing diagnosis and etiology is necessary when modifying a plan. The nurse must assess before revising, delegating and applying medication. The breakdown may be a result of inadequate nutritional intake and medication cannot be applied unless there is an order.
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