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 B
Explanation
Telling the parents “Don’t worry, I’m sure he will be fine” is an example of false reassurance.
This statement does not provide any factual information about the child’s condition and may give the parents a false sense of security.
Telling the parents that their child will receive prompt care [A], that the hospital cares for many 5-year-olds [C], or that the nurse has been a pediatric nurse for ten years [D] are not examples of false reassurance.
These statements provide factual information and may help to reassure the parents without giving them false hope.
Correct Answer is D
Explanation
A fractured hip in an elderly person can be a life-threatening injury due to the risk of complications such as blood clots, pneumonia, and infection.
It is important for the nurse to assess the man’s pain level, vital signs, and overall condition and initiate appropriate interventions as soon as possible.
Choice A) A client with acute diarrhea may require prompt attention to prevent dehydration, but it is not as urgent as a fractured hip.
Choice B) A client who is anxious may benefit from interventions to reduce anxiety, but it is not a life-threatening condition.
Choice C) A woman who feels isolated may benefit from social support and interventions to address her emotional needs, but it is not an urgent medical condition.
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