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 on 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
Relieving pressure from the heel is essential to prevent further damage to the skin and underlying tissues. This can be achieved by using specialized cushions, repositioning the client regularly, or elevating the foot to reduce pressure.
While documenting the reddened area is important to monitor the progression of the wound, asking the client how the area became reddened and assessing their diet may not be the most relevant interventions in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The temperature and respiratory rate in this set are within normal limits. However, the low pulse rate and the high blood pressure are significant findings that require further evaluation. A pulse rate of 54 bpm may indicate a slow heart rate, which can lead to decreased cardiac output and other related symptoms.
A blood pressure of 196/114 mmHg is significantly higher than normal and may indicate hypertension, which can lead to serious health complications if left untreated.
Correct Answer is A
Explanation
The statement "Take naps when drowsy" is not appropriate client education for a client experiencing insomnia. Insomnia is a sleep disorder characterized by difficulty falling or staying asleep, or waking up too early in the morning. Napping during the day can make it harder for someone with insomnia to fall asleep at night. Therefore, advising a client with insomnia to take naps when drowsy can exacerbate their sleep problem.
Regular exercise can improve the quality and duration of sleep.
Limiting fluids before bedtime can reduce the need to wake up during the night to use the bathroom.
Alcohol can disrupt sleep as well, so limiting or avoiding alcohol before bedtime can help improve sleep quality.
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