Basic Care and Comfort NCLEX PN Questions Nursing Practice Question
The nurse is caring for the client with a stage III pressure ulcer to the right heel. Which actions should the nurse plan? Select all that apply.
Correct Answer: A,B,C,E,F
Rationale: Encouraging foods high in vitamin C (A) supports collagen synthesis, essential for wound healing. Premedicating with analgesics (B) minimizes pain during dressing changes, improving patient comfort. Monitoring pedal pulses and capillary refill (C) ensures adequate blood flow to the affected area, crucial for healing. Turning and repositioning the client every 1 to 2 hours (E) prevents further pressure damage. Elevating the extremity (F) helps reduce pressure on the heel.
Using hydrogen peroxide (D) is inappropriate as it can damage healthy tissue and delay healing.