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rpaleo rpaleo
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6 years ago
The nurse caring for a patient with a pressure ulcer notes the wound is increasing in redness and has more swelling around the wound edges. Which nursing intervention is indicated?
1. Encourage the patient to ingest more fluids.
2. Assess for pain and warmth.
3. Cover the wound with a sterile dry dressing.
4. Dress the wound as prescribed.
Textbook 
High-Acuity Nursing

High-Acuity Nursing


Edition: 6th
Authors:
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koccikocci
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#1
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6 years ago
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Rationale 1: Encouraging fluids will not reduce the inflammation that is occurring in the wound.
Rationale 2: The cardinal signs of an inflammation exist in a wound that is infected and include redness, edema, pain, and warmth. Since the patient's wound is demonstrating redness and edema, the nurse needs to assess for pain and warmth to aid in determining if the wound is inflamed and infected.
Rationale 3: Covering the wound with a sterile dry dressing will not address the potential for infection that exists.
Rationale 4: Simply dressing the wound according to previous order will not address the change that has occurred.
1

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rpaleo Author
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#2
6 years ago
Your answer eliminated any doubt I had, thanks
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