The nurse is caring for a client who is diagnosed with an arterial insufficiency ulcer. The nurse should plan interventions to address which priority issue?

A. Remove heel boots:
Heel boots are often used to protect the heels from pressure ulcers. However, it's important to assess the skin regularly and remove heel boots periodically to inspect the skin underneath. Leaving them on continuously without proper inspection can cause moisture buildup, leading to skin breakdown.

B. Reposition every 3 hours
Repositioning the client every 3 hours is a crucial intervention to prevent skin breakdown, especially in individuals at risk, such as older adults. Prolonged pressure on specific areas of the body can lead to pressure ulcers or bedsores. Regular repositioning helps relieve pressure on vulnerable areas, improving circulation and reducing the risk of skin breakdown.

C. Apply cornstarch to keep the skin dry:
While it's essential to keep the skin clean and dry, using cornstarch can sometimes lead to moisture retention, especially in skin folds. Excess moisture can contribute to skin breakdown and fungal infections. Instead, proper hygiene practices and the use of moisture-wicking products are recommended.

D. Provide high protein diet:
Adequate nutrition, including a high-protein diet, is essential for overall skin health and healing. Protein is necessary for tissue repair and regeneration. While a balanced diet is crucial for overall health, it is not a specific intervention solely focused on maintaining skin integrity.

A. Foam:
Explanation: Foam dressings are highly absorbent and provide cushioning and protection to wounds. They are suitable for wounds with moderate to heavy drainage. While foam dressings are excellent for wound exudate management, they are not specifically designed for protecting bony prominences or areas with poor skin integrity.

B. Non-adherent:
Explanation: Non-adherent dressings are made from materials that do not stick to the wound bed. They are ideal for fragile skin, bony prominences, or superficial wounds where minimizing trauma during dressing changes is important. Non-adherent dressings are often used for preventing further skin damage in malnourished clients with poor skin integrity.

C. Ace bandage:
Explanation: Ace bandages, or elastic bandages, are primarily used for providing compression and support to injured joints or muscles. They are not designed for protecting bony prominences or fragile skin areas. Using an Ace bandage on a bony prominence could lead to pressure points and skin damage.

D. Hydrocolloid:
Explanation: Hydrocolloid dressings are absorbent and form a gel-like barrier when they come into contact with wound exudate. They provide a moist environment that supports healing and autolytic debridement. Hydrocolloid dressings are suitable for wounds with light to moderate drainage. While they are beneficial for certain wounds, they are not specifically indicated for protecting bony prominences in malnourished clients.