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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Tell me more about it.” This statement acknowledges the difficulty of the situation and invites the patient to share their feelings and thoughts.
Choice A is incorrect because it does not acknowledge the patient’s current feelings and offers false reassurance.
Choice C is incorrect because it does not acknowledge the patient’s current feelings and may come across as intrusive.
Choice D is incorrect because it does not acknowledge the patient’s current feelings and offers false reassurance.
Correct Answer is A
Explanation
“Do you know how to change your dressing?” This statement can create a barrier to communication because it may make the patient feel judged or defensive if they do not know how to change their dressing.
It is better to phrase the question in a more open-ended and non-judgmental way, such as “Can you tell me about your experience with changing your dressing?”
Choice B is not an answer because it encourages the patient to share information about their hospitalization and promotes open communication.
Choice C is not an answer because it shows that the speaker is actively listening and engaging with the patient’s previous statements.
Choice D is not an answer because it encourages the patient to share information about their pain management and promotes open communication.
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