The mother of a newborn baby is concerned that the baby will develop illnesses from being around people from outside the family. What is the nurse’s best response?

Choice A reason: Deeply palpating the area for rebound tenderness is not the nurse's next action, because it is inappropriate and dangerous. Deeply palpating the area for rebound tenderness is a test that involves applying and releasing pressure on the abdomen, which can elicit pain or discomfort in the presence of peritonitis or appendicitis. Deeply palpating the area for rebound tenderness is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Deeply palpating the area for rebound tenderness can also worsen the pain, damage the tissues, or dislodge the clot, which can cause pulmonary embolism, which is a lifethreatening condition.

Choice B reason: Percussing over the area for a change in tone is not the nurse's next action, because it is inappropriate and useless. Percussing over the area for a change in tone is a test that involves tapping on the chest or abdomen, which can produce different sounds depending on the density of the underlying organs or tissues. Percussing over the area for a change in tone is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Percussing over the area for a change in tone can also worsen the pain, damage the tissues, or dislodge the clot, which can cause pulmonary embolism, which is a lifethreatening condition.

Choice C reason: Comparing the circumference to the left calf is the nurse's next action, because it is appropriate and useful. Comparing the circumference to the left calf is a test that involves measuring the size of the leg, which can reveal any swelling or edema in the affected area. Comparing the circumference to the left calf is relevant and useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Comparing the circumference to the left calf can also help diagnose, monitor, or treat the condition, as a difference of more than 2 cm between the legs can suggest a DVT.

Choice D reason: Medicating the client for pain and reassessing in 60 minutes is not the nurse's next action, because it is inappropriate and delayed. Medicating the client for pain and reassessing in 60 minutes is an intervention that involves giving the client a painkiller and checking the response after an hour. Medicating the client for pain and reassessing in 60 minutes is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Medicating the client for pain and reassessing in 60 minutes can also mask the symptoms, delay the diagnosis, or miss the opportunity to prevent the complications, such as pulmonary embolism, which is a lifethreatening condition.

Choice A reason: Padding hard surfaces is a nursing intervention that decreases the risk of pressure injuries, because it reduces the pressure, shear, and friction on the skin and underlying tissues. Hard surfaces, such as bed rails, wheelchair arms, or footrests, can cause compression or irritation of the skin, especially over the bony prominences. Padding hard surfaces with foam, gel, or air cushions can provide protection and comfort for the client.

Choice B reason: Keeping head of bed (HOB) at or less than 30 degrees is a nursing intervention that decreases the risk of pressure injuries, because it prevents the sliding or shifting of the client in bed. Sliding or shifting can cause shear and friction on the skin, especially over the sacrum, coccyx, or heels. Keeping head of bed (HOB) at or less than 30 degrees can maintain the alignment and stability of the client in bed.

Choice C reason: Keeping head of bed (HOB) elevated to 75 degrees is not a nursing intervention that decreases the risk of pressure injuries, but rather one that increases the risk of pressure injuries. Elevating the head of bed (HOB) to 75 degrees can cause the client to slide or shift in bed, which can increase the shear and friction on the skin, as explained above. Elevating the head of bed (HOB) to 75 degrees can also increase the pressure on the sacrum, coccyx, or heels, which can impair the blood flow and oxygen delivery to the skin and tissues.

Choice D reason: Having client sit in wheelchair as much as possible is not a nursing intervention that decreases the risk of pressure injuries, but rather one that increases the risk of pressure injuries. Sitting in wheelchair as much as possible can cause prolonged pressure, shear, and friction on the skin and underlying tissues, especially over the ischial tuberosities, sacrum, coccyx, or heels. Sitting in wheelchair as much as possible can also reduce the mobility and activity of the client, which can affect the blood circulation and muscle tone.

Choice E reason: Placing pillows between bony surfaces is a nursing intervention that decreases the risk of pressure injuries, because it relieves the pressure, shear, and friction on the skin and underlying tissues. Bony surfaces, such as the ankles, knees, hips, or elbows, can cause compression or irritation of the skin, especially when they are in contact with each other or with the bed. Placing pillows between bony surfaces can provide cushioning and separation for the skin and tissues.