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
Food belongs to the second level of Maslow's hierarchy of needs, which is the physiological needs level. The physiological needs level is the most basic level of the hierarchy and includes the most fundamental needs required for human survival, such as food, water, shelter, and sleep. These needs are considered the most important, as they must be met before an individual can focus on any other needs, such as safety, love and belonging, esteem, and self-actualization.
Correct Answer is C
Explanation
The best thing to do is to involve a professional interpreter when there is a language barrier as the daughter may fail to provide accurate information if there is sensitive information needed.
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