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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The priority action of the nurse to ensure client safety during a transfer from the bed to a wheelchair is to lock the wheels of the wheelchair. This will prevent the wheelchair from moving and provide a stable surface for the client to transfer onto.
Encouraging the client to push up from the wheelchair is not a safe option, as it could result in the client losing their balance and falling.
Ensuring the client is bathed before getting into the wheelchair is not directly related to client safety during the transfer.
Placing the bed in the lithotomy position, which involves positioning the client with their feet in stirrups and their legs elevated, is not necessary for a transfer to a wheelchair and could potentially increase the risk of injury.
Correct Answer is A
Explanation
A complication that may result from decreased mobility is pressure injuries (also known as pressure ulcers or bedsores). When a person remains in one position for extended periods of time, the pressure from their body weight can cause damage to the skin and underlying tissues, particularly in bony areas.
Diarrhea, euphoria, and increased energy are not typically associated with decreased mobility. Diarrhea may be caused by a variety of factors such as infections, food intolerances, or certain medications. Euphoria and increased energy may be associated with certain medical conditions or drug use, but are not directly related to decreased mobility.
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