If a patient has a non-blanchable area of redness on the right malleolus, what stage of pressure injury should be recorded in the patient’s medical record?

Choice A rationale:

Loosening the tape gently by pressing the skin away from it is an important step in changing a burn dressing. However, it is not the first intervention that should be performed. This is because removing the tape can be painful, and it is important to ensure that the patient is adequately pain-free before proceeding.

Choice B rationale:

Observing the wound bed for the presence of granulation tissue is also an important part of burn care. Granulation tissue is a sign of healing, and its presence indicates that the wound is progressing as expected. However, this assessment is not the first priority when changing a dressing. Pain management should always be addressed first.

Choice D rationale:

Gently irrigating the wound using sterile normal saline is another important step in burn care. Irrigation helps to cleanse the wound and remove any debris or dead tissue. However, it should not be performed until the patient's pain has been adequately controlled.

Choice C rationale:

Administering pain medication 30 minutes beforehand is the most important first intervention when changing a painful burn dressing. This allows time for the medication to take effect and ensure that the patient is comfortable before the dressing change begins. Pain management is crucial in burn care, as it can help to reduce anxiety, promote healing, and improve patient outcomes.

Choice A rationale:

While checking intravenous lines for patency and redness is important, it's not the most immediate priority in the post- anesthesia care unit (PACU). Ensuring airway patency and adequate oxygenation takes precedence over IV assessment. Issues with IV lines can usually be addressed quickly if they arise, whereas compromised airway or breathing can rapidly lead to life- threatening complications.

Choice B rationale:

Assessment of nasogastric tubes and bowel sounds is also important, but it's not as urgent as checking the airway and breathing. Bowel sounds may be absent immediately after surgery due to anesthesia and bowel manipulation, and their presence or absence doesn't necessarily indicate an immediate problem. Similarly, nasogastric tubes can be checked and adjusted as needed after ensuring the patient's airway and breathing are stable.

Choice D rationale:

Checking the Foley catheter and surgical fluid intake is essential for monitoring fluid balance and renal function, but it's not a priority over assessing airway, breathing, and circulation (ABCs). Fluid status can be assessed and managed after ensuring the patient's respiratory and circulatory systems are functioning adequately.

Choice C rationale:

Checking the airway, lung sounds, and pulse oximetry is the most critical assessment in the PACU because it ensures that the patient is breathing effectively and has adequate oxygen saturation. This assessment addresses the primary ABCs of patient care:

Airway: The nurse will assess for any obstructions or potential for obstruction, such as swelling, secretions, or the tongue blocking the airway. They will also ensure proper positioning of the head and neck to maintain airway patency.

Breathing: The nurse will listen to lung sounds to evaluate air entry and identify any signs of respiratory distress, such as wheezing, crackles, or decreased breath sounds. They will also monitor respiratory rate and effort.

Circulation: Pulse oximetry measures oxygen saturation in the blood, providing a quick and non-invasive assessment of oxygenation status. It's essential to ensure adequate oxygen delivery to tissues and organs.

By prioritizing the assessment of airway, lung sounds, and pulse oximetry, the nurse can quickly identify and intervene in any respiratory or oxygenation issues, preventing potentially life-threatening complications.