During a hygiene routine, a nurse notices a client has reddened areas on the sacrum. What should be the nurse's first action?
Apply a moisturizing lotion to the area.
Reposition the client to alleviate pressure.
Continue with the hygiene routine and reassess later.
Document the finding in the client's chart.
The Correct Answer is B
A. Applying a moisturizing lotion may help maintain skin integrity but does not address the immediate risk of pressure injury.
B. Repositioning the client to alleviate pressure is the priority action. Reddened areas on bony prominences, such as the sacrum, indicate early signs of pressure injury, and relieving pressure prevents further tissue damage.
C. Continuing with the hygiene routine and reassessing later delays intervention, increasing the risk of progression to a pressure ulcer.
D. Documenting the finding is important, but it is not the first action; immediate interventions to reduce pressure must take precedence to protect skin integrity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. There is no indication of equipment malfunction; the nurse is able to hear Korotkoff sounds, which indicates proper functioning of the sphygmomanometer and stethoscope.
B. The first faint, clear tapping sound heard when inflating and then slowly deflating the cuff represents the systolic blood pressure. In this scenario, the systolic pressure is 110 mm Hg, indicating the pressure at which the heart is pumping blood into the arteries.
C. The diastolic blood pressure is recorded when the sounds disappear, not when they first appear. Therefore, 110 mm Hg is not the diastolic value.
D. While a cuff that is too loose can affect accuracy, the presence of clear tapping sounds suggests that the cuff fit is adequate for obtaining a measurement.
Correct Answer is B
Explanation
A. Assisted living provides support with daily activities but typically does not offer skilled nursing services such as dressing changes for pressure injuries.
B. Home care is appropriate for clients who require skilled nursing interventions at home, such as daily dressing changes, wound assessment, and monitoring for infection. Referral to home care ensures continuity of care and proper wound management in the home environment.
C. Long-term care facilities provide comprehensive care for clients who cannot safely live at home, but this level of care may not be necessary if the client is otherwise independent.
D. Hospice care is focused on end-of-life comfort rather than routine wound management for clients who are not terminally ill.
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