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 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
The best intervention by the nurse to prevent further skin and tissue breakdown on a reddened area on a client’s right heel is to relieve pressure from the right heel1.
Heels are particularly vulnerable to skin breakdown and when patients lie supine, all of the pressure of their lower legs and feet rest on the heels1.
Preventing heel ulcers primarily involves the use of simple devices, like pillows and offloading devices, to protect delicate heels1.
Choice A is not correct because documenting the reddened area alone will not prevent further skin and tissue breakdown.
Choice B is not correct because asking the client how the area became reddened alone will not prevent further skin and tissue breakdown.
Choice C is not correct because assessing the client’s diet alone will not prevent further skin and tissue breakdown.
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Related Questions
Correct Answer is C
Explanation
Food belongs to the physiological level of Maslow’s Hierarchy of Needs1.
This is the lowest level of the hierarchy and includes basic needs that are vital to survival, such as food, water, and shelter1.
Choice A is incorrect because love and belonging are at a higher level of Maslow’s Hierarchy of Needs and do not include food.
Choice B is incorrect because safety and security are also a higher level of Maslow’s Hierarchy of Needs and do not include food.
Choice D is incorrect because esteem is a higher level of Maslow’s Hierarchy of Needs and does not include food.
Correct Answer is D
Explanation
Encouraging bed rest would be an inappropriate nursing intervention to promote mobility for a client with decreased mobility.
Bed rest can lead to further complications of immobility1.
Choice A is not an answer because teaching the client to do active range of motion (AROM) exercises every 2 hours can help maintain joint mobility and muscle strength2.
Choice B is not an answer because evaluating the client’s need for ambulatory aids can help them move safely and independently1.
Choice C is not an answer because keeping skin clean and dry is important for preventing skin breakdown, which can be a complication of immobility1.
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