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 C
Explanation
The priority responsibility of the nurse is to call for a Cambodian interpreter.
This ensures that the mother’s needs and concerns are accurately communicated and understood.
It also helps to prevent any misunderstandings or miscommunications that could occur if the daughter were to interpret.
Choice A is not an appropriate response because calling the chaplain for support may not address the language barrier.
Choice B is not an appropriate response because allowing unlicensed assistive personnel to interpret could result in inaccurate or incomplete information being conveyed.
Choice D is not an appropriate response because continuing to work with the daughter for interpretation could result in misunderstandings or miscommunications.
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