A 74 year old female is admitted to the hospital with a diagnosis of 'wound infection.' She is non- verbal with a previous history of a stroke that has left her wheelchair bound. Her vital signs are: Temp 101.6 F, heart rate 100, respiratory rate 20, pulse ox 96%. On assessment her left arm is warm to the touch with fluid filled vesicles noted. Some of the vesicles appear to be excoriated. The right arm appears normal. When turning the patient her sacrum is noted to be red but blanches when touched. Her left heel is noted to be very soft, and mushy feeling, with a blood blister that is intact on it. Based on the above findings the nurse should do all of the following: Multiple options may be correct

A. Elevate the patient's left leg: Elevating the affected left leg helps reduce edema, improve venous return, and minimize pressure on the deep tissue injury at the heel. This intervention also promotes circulation, reduces pain, and supports healing of the compromised tissue. Proper limb positioning is a critical nursing action for localized wound management. B. Place the patient on isolation precautions: The presence of excoriated fluid-filled vesicles on the left arm suggests a potentially contagious infection, such as bacterial impetigo or viral lesions. Implementing isolation precautions helps prevent the spread of infection to staff, other patients, and visitors, ensuring both patient and public safety. C. Plan on patient needing pain medication: Wounds, excoriated vesicles, and deep tissue injuries are typically painful, especially during repositioning, dressing changes, or movement. Anticipating and providing pain management enhances patient comfort, promotes cooperation with care, and prevents stress-related physiological complications that could impair healing. D. Sit the patient up in a wheelchair: While upright positioning may be beneficial for some patients, placing this patient in a wheelchair could increase pressure on already compromised areas such as the sacrum and heels. Given her immobility and risk for pressure injuries, sitting upright without proper support could exacerbate tissue damage rather than support healing. E. Apply a moist compress to the right arm for patient comfort: The right arm appears normal on assessment, with no lesions or inflammation. Applying a moist compress to a healthy area is unnecessary and does not address the patient’s immediate needs or comfort. Nursing interventions should focus on affected areas and systemic concerns.