A Client Has a Wound on His Left Trochanter That

question 35

Multiple Choice

A client has a wound on his left trochanter that is 4 inches in diameter,with black tissue at the perimeter,and bone is exposed.Which is the nurse's best action?

• A) Document as a stage I pressure ulcer and apply a transparent dressing.
• B) Document as a stage II pressure ulcer and start wet-to-dry gauze treatments.
• C) Document as a stage III pressure ulcer and start antibiotic therapy.
• D) Document as a stage IV pressure ulcer and prepare the client for débridement.

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