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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Inform the client that driving would be dangerous.
Narcolepsy is a sleep disorder characterized by excessive daytime sleepiness and sudden attacks of sleep.
As a result, it can be dangerous for individuals with narcolepsy to engage in activities that require sustained attention and alertness, such as driving.
The nurse’s priority intervention would be to inform the client of this risk and advise them to avoid driving.
Choice A is not an answer because while avoiding caffeine after 6 pm may help improve sleep quality, it is not the priority intervention for a client with narcolepsy.
Choice B is not an answer because drinking two cups of regular coffee may worsen the symptoms of narcolepsy and is not a recommended intervention.
Choice C is not an answer because while participating in normal activities may be beneficial for overall health and well-being, it is not the priority intervention for a client with narcolepsy.
Correct Answer is A
Explanation
Bounding pulses are not a sign of inadequate perfusion.
Inadequate perfusion is when blood flow to a specific part of your body is reduced and that part will not receive essential nutrients.
Signs of inadequate perfusion include cyanosis (bluish discoloration of the skin due to lack of oxygen), pallor (paleness of the skin), and coolness1.
Choice B is incorrect because cyanosis is a sign of inadequate perfusion.
Choice C is incorrect because pallor is a sign of inadequate perfusion.
Choice D is incorrect because coolness is a sign of inadequate perfusion.
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