Question

A home health nurse is providing teaching to a client who has stage 1 pressure injury on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching?

(A) Avoid sitting in the same position for more than 30 minutes at a time.
(B) Use a pressure-relieving mattress or overlay.
(C) Keep the skin around the pressure injury clean and dry.
(D) Apply a topical antibiotic to the pressure injury.
(E) All of the above

Answer 1

The nurse should advise the client to avoid sitting in the same position for more than 30 minutes, use a pressure-relieving mattress, and keep the area clean and dry. The use of a topical antibiotic should be under medical advice.

Step-by-step explanation:

The home health nurse should include multiple instructions for a client with a stage 1 pressure injury on the greater trochanter of the left hip. Firstly, it is crucial to avoid sitting in the same position for more than 30 minutes at a time to reduce the constant pressure on the injury. Secondly, the use of a pressure-relieving mattress or overlay can redistribute the weight and alleviate the stress on the affected area. Keeping the skin around the pressure injury clean and dry is essential to prevent infection and promote healing. While topical antibiotics can be used in some cases, this should be done under medical advice, as they are not always necessary for the early stages of a pressure sore. Therefore, the correct instructions would be (A), (B), and (C), as these are general preventive measures for managing a pressure injury. Using a topical antibiotic, as mentioned in (D), should only be done if prescribed by a healthcare professional. Considering this, the correct filled option would be (E) All of the above, with the assumption that the use of a topical antibiotic is based on medical advice.