Certified Wound Care Nurse (CWCN) Practice Exam 2025 – Complete Prep Resource

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In caring for a patient with a sacral pressure ulcer, what is the most important action?

Insert a Foley catheter.

Turn and reposition the patient at least every 2 hours.

Add supplemental protein to the diet.

Assist the patient to ambulate and sit in a chair 3 times a day.

The most important action in caring for a patient with a sacral pressure ulcer involves turning and repositioning the patient at least every 2 hours. This action is crucial because pressure ulcers, also known as decubitus ulcers, develop due to prolonged pressure on the skin, particularly over bony prominences such as the sacrum. Regular repositioning relieves this pressure, promoting circulation and allowing any existing ulcers to heal while preventing new ones from forming. Maintaining proper skin integrity is vital in preventing complications associated with immobility and is a foundational aspect of wound care management.

While assisting the patient to ambulate and sit in a chair is beneficial for their overall health and circulation, it does not replace the necessity of frequent repositioning, which is essential for mitigating the risk of pressure ulcers. Although adding supplemental protein to the diet supports healing, and inserting a Foley catheter might be necessary in specific cases, these actions do not address the immediate mechanical causes of pressure ulcer formation in the way that regular repositioning does. Therefore, ensuring the patient is turned and repositioned consistently is the most critical nursing intervention in this scenario.

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