While bathing a patient who is on bedrest, the nurse notes an area of blistering and hypopigmentation on the patient's right heel. Upon further assessment, the area is also tender and cooler than the surrounding area. What is the next best action by the nurse?
Palpate for pedal pulses.
Turn the patient every three hours.
Document the stage 1 pressure injury.
Elevate bilateral heels.
The Correct Answer is A
A. Palpate for pedal pulses: Cool skin may indicate poor circulation or ischemia. Checking pedal pulses helps assess blood flow. This step provides essential information about the vascular status of the patient's foot, guiding further interventions.
B. Turn the patient every three hours: Patients on bedrest should be turned every 2 hours, not every 3 hours, to prevent pressure injuries.
C. Document the stage 1 pressure injury: Blistering indicates at least a Stage 2 pressure injury, not Stage 1. The nurse must assess further before staging.
D. Elevate bilateral heels: Once assessment confirms the need, elevating the heels can help reduce pressure and promote circulation, potentially preventing further damage and aiding in the healing process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Educate the patient about hand hygiene with alcohol-based hand sanitizer: Standard precautions apply to all patients, including hand hygiene education. HIV is not transmitted through casual contact.
B. Notify the patient's spouse about the result and arrange for HIV testing: Patient confidentiality must be maintained. The patient should be encouraged to inform their partner, but the nurse cannot disclose the results.
C. Provide information on antibiotic therapy to help control the infection: HIV is a viral infection, not bacterial. Antibiotics do not treat HIV.
D. Initiate contact precautions with gown and gloves: HIV is bloodborne and not spread via casual contact, so contact precautions are not required unless the patient has an open wound or secondary infection.
Correct Answer is C
Explanation
A. Check the patient's urinalysis. While a urinalysis may provide useful information (e.g., infection, kidney function), it does not address the immediate concern—significantly decreased urine output despite adequate intake. The priority is to determine urinary retention first.
B. Notify the provider of the patient's pain 7/10. While pain management is important, the more critical issue is the drastically low urine output (150mL in 12 hours), which could indicate acute urinary retention or renal dysfunction. Addressing the urinary issue should come first.
C. Perform a bladder scan. The low urine output (150mL in 12 hours) despite sufficient intake (2150mL) suggests potential urinary retention. A bladder scan is the quickest and least invasive way to determine if the patient has a full bladder that needs intervention (e.g., catheterization). This is the priority before further testing or notifying the provider.
D. Assess the daily weight. Daily weight monitoring is helpful for fluid status assessment, especially in cases of heart failure or kidney disease, but it is not the most immediate priority. The primary concern is whether the patient has urinary retention, which requires urgent evaluation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.