A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

Choice A Reason:

“Prevents pressure ulcers” is incorrect. While positioning can help prevent pressure ulcers, the orthopneic position is specifically used to aid in breathing rather than to prevent pressure ulcers. Pressure ulcers are typically managed by regularly repositioning the client and using pressure-relieving devices.

Choice B Reason:

“Supports hip extension” is incorrect. The orthopneic position does not primarily support hip extension. This position involves sitting up and leaning forward, which does not significantly affect the hips.

Choice C Reason:

“Facilitates breathing” is correct. The orthopneic position, also known as the tripod position, helps to improve breathing in clients with COPD. By leaning forward and resting the arms on a table or knees, the diaphragm can move more freely, and accessory muscles of respiration are better utilized, reducing the work of breathing.

Choice D Reason:

“Promotes urinary elimination” is incorrect. The orthopneic position is not intended to promote urinary elimination. Urinary elimination is typically managed through other interventions such as ensuring adequate hydration and, if necessary, using a catheter.

Choice A reason: Thrombophlebitis is characterized by inflammation of the vein with the formation of a blood clot. The signs and symptoms include erythema, warmth, edema, and a red line traveling up the vessel, which indicates the presence of inflammation and possible clot formation. This condition requires prompt intervention to prevent further complications such as the spread of infection or the clot traveling to other parts of the body.

Choice B reason: Infiltration occurs when IV fluid or medication leaks into the surrounding tissue. Signs of infiltration include swelling, discomfort, and coolness at the IV site, but it does not typically present with erythema, warmth, or a red line traveling up the vessel. Infiltration is less likely to cause the systemic signs seen in this case.

Choice C reason: Infection at the IV site can cause erythema, warmth, and edema, but it usually does not present with a red line traveling up the vessel. The red line is more indicative of thrombophlebitis, where the inflammation follows the path of the vein. Infection would also likely present with additional systemic signs such as fever.

Choice D reason: Extravasation involves the leakage of vesicant drugs into the surrounding tissue, causing severe local tissue damage. Signs include pain, burning, and blistering at the site, but it does not typically present with a red line traveling up the vessel. Extravasation is more localized and does not follow the vein’s path like thrombophlebitis.