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
Asking “What types of food do you eat for meals and between meals?” is considered a culturally sensitive question because it shows respect for the individual’s dietary habits and preferences.
Choice A is not correct because asking “Are you required to pray in a certain way at certain times?” may come across as intrusive or judgmental.
Choice C is not correct because asking “Are you familiar with the way we prepare meals?” may come across as presumptuous or dismissive of the individual’s cultural background.
Choice D is not correct because asking “Are you okay with not having kosher meals?” may come across as dismissive of the individual’s dietary needs or religious beliefs.
Correct Answer is C
Explanation
The nurse’s priority action when an eight-year-old child is eating a hotdog and begins coughing is to promote coughing.
Coughing is the body’s natural way of trying to clear an obstruction from the airway.
Choice A is not the correct answer because beginning the Heimlich maneuver quickly is not the first action that should be taken.
Choice B is not the correct answer because telling the child to put his hands by his neck to signify that he is choking is not the first action that should be taken.
Choice D is not the correct answer because leaving the child alone to find a phone is not the first action that should be taken.
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