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 mission of the Occupational Safety and Health Administration (OSHA) is to ensure safe and healthy working conditions for employees in the United States by setting and enforcing workplace safety and health standards, providing training and education, and promoting best practices in occupational safety and health.
Correct Answer is A
Explanation
If a fire is found in a client's room during a routine medication pass, the nurse's first action should be to activate the fire alarm. Activating the fire alarm will alert other staff members and activate the fire suppression system, which can help to contain the fire and prevent it from spreading to other areas of the facility. This will also initiate the evacuation of other clients and staff members, as well as alert the fire department.
Once the fire alarm has been activated, the nurse should safely evacuate the client and themselves from the room, if possible, and then notify the supervisor and the fire department.
Containing the fire or attempting to put it out should only be done if it can be done safely and without putting oneself or others at risk.
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