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 on 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
Relieving pressure from the heel is essential to prevent further damage to the skin and underlying tissues. This can be achieved by using specialized cushions, repositioning the client regularly, or elevating the foot to reduce pressure.
While documenting the reddened area is important to monitor the progression of the wound, asking the client how the area became reddened and assessing their diet may not be the most relevant interventions in this situation.
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Related Questions
Correct Answer is C
Explanation
The intervention the nurse can implement to improve communication with an older client who is wearing a hearing aid is to speak loudly and clearly. Speaking loudly and clearly can help the client to better understand what is being said, especially if they are experiencing hearing loss. However, it is important for the nurse to speak clearly without shouting, as shouting can distort speech and make it more difficult for the client to understand.
Chewing gum can actually hinder communication, as it can affect speech clarity and create distracting noises.
Turning off the television can help to reduce background noise and make it easier for the client to hear, but it may not be necessary in all cases.
Using a paper and pencil can be helpful in some situations, but it may not be necessary if the client is able to hear and understand verbal communication.
Correct Answer is ["B","C","E"]
Explanation
Echinacea is commonly used to boost the immune system and prevent colds and other infections.Ginseng is a stimulant that is often used to improve physical performance and reduce fatigue. Aloe is a natural anti-inflammatory and antibacterial agent that is often used to promote healing of burns, cuts, and other skin injuries.
Ginkgo biloba does not cause fibrin clot formation, but rather has been shown to have an anticoagulant effect, meaning it can decrease the clotting ability of the blood. Chamomile is not known for enhancing the immune response to influenza A, but rather for its calming effects and its use as a sleep aid.
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