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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Related Questions
Correct Answer is C
Explanation
Locking the wheels of the wheelchair is a priority action of the nurse to ensure client safety during a transfer from the bed to a wheelchair.
This prevents the wheelchair from moving or rolling away during the transfer, which could result in injury to the client.
Choice A is not an appropriate response because encouraging the client to push up from the wheelchair may not be safe or feasible for all clients.
Choice B is not an appropriate response because ensuring the client is bathed before getting into the wheelchair is not directly related to client safety during the transfer.
Choice D is not an appropriate response because placing the bed in the trendelenburg position could make it more difficult for the client to transfer
Correct Answer is B
Explanation
To prevent poisoning of a child in the home, it is important to keep cleaning liquids and other potential poisons in a locked cabinet12.
This includes storing medicines, chemicals, and cleaners up high in a locked cupboard and in their original containers1.
Choice A is incorrect because it focuses on prescription medications and not on preventing the poisoning of a child in the home.
Choice C is incorrect because it focuses on taking medications correctly and not on preventing the poisoning of a child in the home.
Choice D is incorrect because storing medications in a visible and accessible place could increase the risk of poisoning if a child were to access them.
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