A client has a reddened area on his right heel.
What is the best intervention by the nurse to prevent further skin and tissue breakdown?
Document the reddened area
Ask the client how the area became reddened
Assess the client's diet
Relieve pressure from the right heel
The Correct Answer is D
The best intervention by the nurse to prevent further skin and tissue breakdown on a reddened area on a client’s right heel is to relieve pressure from the right heel1.
Heels are particularly vulnerable to skin breakdown and when patients lie supine, all of the pressure of their lower legs and feet rest on the heels1.
Preventing heel ulcers primarily involves the use of simple devices, like pillows and offloading devices, to protect delicate heels1.
Choice A is not correct because documenting the reddened area alone will not prevent further skin and tissue breakdown.
Choice B is not correct because asking the client how the area became reddened alone will not prevent further skin and tissue breakdown.
Choice C is not correct because assessing the client’s diet alone will not prevent further skin and tissue breakdown.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The best intervention by the nurse to prevent further skin and tissue breakdown on a reddened area on a client’s right heel is to relieve pressure from the right heel1.
Heels are particularly vulnerable to skin breakdown and when patients lie supine, all of the pressure of their lower legs and feet rest on the heels1.
Preventing heel ulcers primarily involves the use of simple devices, like pillows and offloading devices, to protect delicate heels1.
Choice A is not correct because documenting the reddened area alone will not prevent further skin and tissue breakdown.
Choice B is not correct because asking the client how the area became reddened alone will not prevent further skin and tissue breakdown.
Choice C is not correct because assessing the client’s diet alone will not prevent further skin and tissue breakdown.
Correct Answer is D
Explanation
Inform the client that driving would be dangerous.
Narcolepsy is a sleep disorder characterized by excessive daytime sleepiness and sudden attacks of sleep.
As a result, it can be dangerous for individuals with narcolepsy to engage in activities that require sustained attention and alertness, such as driving.
The nurse’s priority intervention would be to inform the client of this risk and advise them to avoid driving.
Choice A is not an answer because while avoiding caffeine after 6 pm may help improve sleep quality, it is not the priority intervention for a client with narcolepsy.
Choice B is not an answer because drinking two cups of regular coffee may worsen the symptoms of narcolepsy and is not a recommended intervention.
Choice C is not an answer because while participating in normal activities may be beneficial for overall health and well-being, it is not the priority intervention for a client with narcolepsy.
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