A Medical-Surgical 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?

Choice A rationale:

Repositioning the client every 3 hours is a crucial intervention to prevent skin breakdown in older adults who are immobile or have limited mobility. Prolonged pressure on certain areas can lead to ischemia and tissue damage, particularly over bony prominences. Repositioning helps to distribute pressure evenly, maintain circulation, and reduce the risk of pressure ulcers.

Choice B rationale:

Massage of bony prominences is not recommended as a preventive measure for skin breakdown. Massaging these areas can actually cause friction and shear forces, leading to further damage to the delicate skin of older adults. Gentle repositioning and maintaining proper skin hygiene are more effective strategies.

Choice C rationale:

While a diet high in protein is important for overall health, it is not a direct intervention for maintaining the integrity of the client's skin. Protein is necessary for wound healing and tissue repair, but it doesn't address the primary concern of preventing skin breakdown due to pressure.

Choice D rationale:

Applying cornstarch to keep the skin dry is not a recommended practice for preventing skin breakdown. Excessive moisture can contribute to skin breakdown, but cornstarch may not be the best solution. Proper hygiene, gentle cleansing, and appropriate use of moisture-barrier products are more effective in maintaining skin integrity.

Choice A rationale:

Enclosing the dressing in a single clear plastic bag and discarding it in the bedside trash receptacle is not the appropriate method for disposing of a dressing saturated with blood and purulent drainage. Blood and purulent drainage are considered potentially infectious materials, and they should be handled as biohazardous waste to prevent the spread of infection.

Choice B rationale:

This is the correct choice. When dealing with potentially infectious materials such as blood and purulent drainage, it's essential to dispose of them in a biohazardous waste container. This specialized container is designed to contain potentially infectious materials and prevent their spread, thereby protecting both healthcare workers and the environment.

Choice C rationale:

Discarding the dressing in the bedside trash receptacle is not the recommended approach for disposing of materials that are contaminated with blood and purulent drainage. Simply discarding it in the regular trash increases the risk of infection transmission and is not compliant with proper infection control practices.

Choice D rationale:

Double-bagging the dressing in clear bags and labeling it "biohazard" is a good practice to ensure proper containment. However, it's not the most comprehensive method of disposal. Placing the dressing in a dedicated biohazardous waste container is a more secure and standardized method for disposing of potentially infectious materials.