A nurse is developing a plan of care for a client who has a stage pressure ulcer. Which of the following interventions should the nurse include in the plan?

The correct answer is C.

A: Consulting a dietitian is a beneficial order for a patient with a pressure ulcer. Proper nutrition, especially adequate protein intake, is crucial for wound healing. A dietitian can help ensure the patient receives the necessary nutrients to support tissue repair and recovery.

B: Applying a hydrogel dressing is appropriate for a clean, granulating Stage II pressure ulcer. Hydrogel dressings maintain a moist wound environment, which promotes healing and provides pain relief. They are suitable for wounds with minimal to moderate exudate.

C: Cleaning the wound with hydrogen peroxide is not recommended for a healing pressure ulcer. Hydrogen peroxide can damage healthy granulating tissue and delay the healing process. It is better to use saline or a wound cleanser that does not harm the new tissue.

D: Using a low-air-loss therapy unit is beneficial for patients with pressure ulcers. These units help reduce pressure on the skin, improve circulation, and prevent further skin breakdown. They are an effective part of pressure ulcer management.

A: The nurse should check the medication order again to ensure that the correct medication is being administered. This response addresses the client’s concern and ensures patient safety.

B: Telling the client that this is the medication their doctor wants them to take does not address the client’s concern about the color difference and may not ensure the correct medication is given.

C: While it is true that the same medication can come in different colors, this response does not verify the accuracy of the medication being administered.

D: Explaining the purpose of the medication is important, but it does not address the immediate concern about the color difference and the need to verify the medication.