A nurse is caring for a client who has a pressure injury on the coccyx. Which of the following findings should indicate to the nurse that the wound is a stage III pressure injury?

A. Maintain a constant, gentle suction on the drainage device: A portable wound bulb suction device is used to remove blood and serous fluid, prevent hematoma or seroma formation, and promote wound healing. Maintaining constant, gentle suction ensures effective drainage and reduces the risk of complications such as infection or fluid accumulation.

B. Place the client in the supine position while resting in bed: After a mastectomy, clients are typically positioned with the head of the bed elevated and the affected arm supported on a pillow to reduce swelling and promote comfort. Supine positioning without support may increase tension on the surgical site and impair drainage.

C. Prepare to remove the drainage tube 24 hr after the procedure: Drainage tubes are usually removed when output is minimal, often 24–48 hours or longer depending on the volume and type of drainage. Removing the tube at a fixed 24-hour mark may be premature and could increase the risk of fluid accumulation.

D. Notify the provider for drainage of 25 mL in 24 hr: Drainage of 25 mL in 24 hours is minimal and typically does not require provider notification. Normal early postoperative drainage is expected, and the nurse should continue routine monitoring and documentation rather than escalate care for this amount.

Rationale

• Encourage rigorous physical exercise to enhance mobility: While exercise can improve function, rigorous or high-intensity activity may exacerbate fatigue or trigger worsening of symptoms in MS. Exercise should be tailored to the client’s tolerance and done under professional guidance rather than encouraged rigorously at home. Overexertion may increase relapse risk or cause injury.

• Instruct the client to remove throw rugs from their home: Removing throw rugs reduces the risk of falls in clients with multiple sclerosis, especially those who have had gait disturbances or lower extremity weakness. Fall prevention is a standard safety intervention in MS care. This addresses environmental hazards and promotes safe ambulation at home.

• Request a provider referral for physical therapy: Physical therapy supports mobility, balance, and strength in clients with MS. PT interventions can help manage spasticity and prevent functional decline. Referral is appropriate for clients who continue to experience daily muscle spasms and intermittent functional limitations.

• Teach the client about self-administering glatiramer acetate: Glatiramer acetate is a disease-modifying therapy for MS, and teaching self-administration promotes adherence, autonomy, and consistent treatment. Education regarding proper technique, injection site rotation, and monitoring for side effects is a standard nursing intervention in MS management.

• Encourage the use of a hot tub to decrease muscle spasms: Hot tubs can exacerbate heat sensitivity in MS, potentially worsening muscle weakness, fatigue, or neurological symptoms. Heat intolerance is common in MS, making hot tub use an inappropriate intervention without professional guidance. Safer spasticity management strategies include stretching, PT, or pharmacologic interventions.