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    ATI ns 550 Fundamentals proctored Exam

    A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

    Explanation & Rationale

    Choice A reason: Hydrogen peroxide can damage healthy tissue and delay healing in stage 3 pressure ulcers. Normal saline or prescribed solutions are preferred, making this an incorrect intervention for wound care. Choice B reason: Massaging reddened areas risks further tissue damage, as pressure exacerbates ischemia in stage 3 ulcers. Avoiding pressure is critical, making this an incorrect and harmful intervention for care. Choice C reason: Applying a heat lamp can dry the wound and cause burns, delaying healing. Moist wound environments promote recovery, making heat application inappropriate for stage 3 pressure ulcer management. Choice D reason: Repositioning every 2 hours relieves pressure on stage 3 ulcers, promoting blood flow and preventing further tissue damage. This is a key intervention for healing, making it the correct choice.

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