A client who has been hospitalized with an exacerbation of heart failure experiences severe dyspnea with activity and remains on bedrest. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

Choice A reason: Evaluating urinary output hourly monitors renal function post-ureterolithotomy, as obstruction or complications may reduce output. However, urine leakage around the catheter suggests dislodgement or ureteral injury, risking peritonitis or infection. Reporting leakage is more urgent, as it indicates a critical catheter malfunction requiring immediate medical attention.

Choice B reason: Clamping the ureteral catheter risks obstructing urine flow, increasing pressure and causing ureteral damage or reflux, potentially leading to hydronephrosis or infection. Leakage around the catheter is a more pressing issue, indicating possible perforation or displacement, necessitating urgent reporting to prevent severe complications.

Choice C reason: Securing the catheter prevents dislodgement but is routine. Urine leakage suggests a critical issue like catheter malfunction or ureteral injury, which could cause peritonitis or fistula. Reporting leakage takes precedence, as it addresses a potentially life-threatening complication, ensuring timely intervention over standard catheter care.

Choice D reason: Reporting urine leakage is critical, as it may indicate catheter displacement or ureteral perforation, risking peritonitis or infection. Leakage suggests the catheter fails to drain urine properly, a serious post-surgical issue requiring immediate assessment, potentially via imaging or surgical correction, to prevent renal or systemic complications.

Choice A reason: Using a heating pad is contraindicated in Raynaud’s, as reduced sensation from vasospasm risks burns. Raynaud’s involves cold-triggered arteriolar constriction, reducing blood flow. Heat does not address vasospasm’s pathophysiology and may cause tissue damage, making this instruction inappropriate compared to cold protection strategies.

Choice B reason: Wearing gloves when handling cold items prevents vasospasm in Raynaud’s, where cold triggers arteriolar constriction, causing ischemia and pain. Protecting extremities maintains blood flow, preventing episodes. This directly addresses the disease’s pathophysiological trigger, making it the most effective instruction for managing Raynaud’s symptoms.

Choice C reason: Knee-high support stockings improve venous return, relevant for venous insufficiency, not Raynaud’s arterial vasospasm. Stockings do not prevent cold-induced vasoconstriction, the primary trigger. Gloves for cold exposure directly mitigate vasospastic episodes, making this instruction less effective for Raynaud’s disease management.

Choice D reason: Regular walking improves overall circulation but does not prevent Raynaud’s vasospastic episodes, triggered by cold or stress. While exercise supports vascular health, avoiding cold exposure with gloves is more targeted, directly reducing arteriolar constriction and ischemic symptoms, making walking a secondary recommendation.