The nurse on the unit is going to perform wound care for her patient.
After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.

Choice A rationale:

Wrapping the dressing in a clear plastic bag and discarding it in the bedside trash receptacle is incorrect because it does not follow proper biohazardous waste disposal protocols.

Choice B rationale:

Double bagging the dressing, labeling it “biohazard,” and sending it for decontamination is incorrect because it is not the standard procedure for disposing of soiled dressings.

Choice C rationale:

Placing the dressing in a biohazardous waste container is the correct method for disposing of soiled dressings.

Choice D rationale:

Discarding the dressing in the bedside trash receptacle is incorrect because it does not follow proper biohazardous waste disposal protocols.

Choice A rationale:

Massaging bony prominences can lead to tissue ischemia and damage, increasing the risk of pressure injuries.

Choice B rationale:

Repositioning should be done every 2 hours or less for at-risk patients.

Choice C rationale:

Elevating the head of the bed more than 30° can increase shear and friction, leading to pressure injuries.

Choice D rationale:

A high-calorie diet can promote skin integrity and wound healing.