A 28-year-old male is a patient at your clinic.
He states that he had a minor accident with his motorcycle 5 days ago.
He sustained several scrapes and wounds.
The wound on his calf has a pinkish-red center area that looks bumpy.
This indicates that the wound is:

Choice A rationale:

An unresponsive client who only occasionally changes position is at the highest risk for developing a pressure injury due to prolonged pressure on certain areas of the body.

Choice B rationale:

A client who is alert and responsive and eats 25% of each meal is at lower risk as they are likely to move more frequently.

Choice C rationale:

A client who makes frequent slight changes in position and walks occasionally is at lower risk due to regular movement.

Choice D rationale:

A client who is receiving enteral feeding and can change position independently is at lower risk as they are able to relieve pressure regularly.

Choice A rationale:

While it’s important for the patient to remain still during the procedure, this is not the most important aspect of changing a sterile dressing.

Choice B rationale:

Placing a discard bag close to the wound can increase the risk of infection.

Choice C rationale:

Changing gloves after removing the old dressing is crucial to maintain sterility and prevent infection.

Choice D rationale:

Refraining from talking while the wound is uncovered can help prevent infection, but it’s not as important as changing gloves after removing the old dressing.