• NCLEX Pretest
  • Time Used 0:00:00

The nurse requests analgesia for the 76-year-old patient who must undergo cleansing and dressing change for a healing stage 3 pressure ulcer on the coccyx. In response, the provider ordered topical EMLA cream to be applied to the wound 30 minutes before the procedure. Which action by the nurse is appropriate?

Correct

  • Apply the medication to the intact, periwound tissue
  • Advocate for an order for intravenous fentanyl dose to be given 15 minutes before the procedure
  • Request a fentanyl patch to be placed on the intact skin of the right hip near the site of the wound
  • Apply the medication to the wound base and surrounding tissue; thoroughly remove the cream during cleansing

Rationale

A stage 3 pressure ulcer wound cleansing and dressing change can be exceedingly painful and appropriate pain management is vital. However, EMLA cream should not be applied to open skin. Therefore, the appropriate nursing action is to advocate for an order for IV fentanyl given 15 minutes before the procedure. Applying the medication to the intact skin around the wound will not result in effective pain management. A fentanyl patch may be necessary to provide long-term management for this patient, but the patch will not provide the acute pain management necessary for the dressing change.

  • Category: Basic Care and Comfort
  • Difficulty: 7
  • Tags: Communication & Documentation Health Promotion Medication and Blood Products Nursing Interventions Routes of Administration Tissue Integrity

Question 18 of 30

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