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 B
Explanation
Tell me more about it.” This statement acknowledges the difficulty of the situation and invites the patient to share their feelings and thoughts.
Choice A is incorrect because it does not acknowledge the patient’s current feelings and offers false reassurance.
Choice C is incorrect because it does not acknowledge the patient’s current feelings and may come across as intrusive.
Choice D is incorrect because it does not acknowledge the patient’s current feelings and offers false reassurance.
Correct Answer is C
Explanation
Inducing vomiting is not always the appropriate first aid response for poisoning and can sometimes be harmful.
It is important to call the poison control center for guidance on what to do if you suspect poisoning1.
Choice A is not an answer because taking prescription medications only as prescribed can help prevent accidental poisoning1.
Choice B is not an answer because sharing prescription medications can be dangerous and lead to accidental poisoning2.
Choice D is not an answer because having the phone number for the poison control center easily accessible can help you quickly get guidance on what to do in case of suspected poisoning1.
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