Fundamentals Question #39

Question

When caring for an immobile client, the nurse notices an area of redness on the client’s left calf. What is the priority intervention for this client?

Answers

  1. Offering the client meals that are high in calories and protein
    • Rationale:
  2. Doing a focused assessment of the extremity
    • Rationale:
  3. Discontinuing the sequential compression device
    • Rationale:
  4. Placing the client's legs in a dangling position for comfort
    • Rationale:

Overview

Explanation

The correct option is B. The nurse will need to assess the client further for the possibility of a deep vein thrombosis. Offering the client meals high in calories and protein will help with decreasing skin breakdown, however that is not the most immediate need of the client. Sequential compression devices would not be discontinued without a prescription from a health care provider. The client’s legs would not be placed in a dependent position but would be elevated.

Learning Outcomes

Test Taking Tip

Video Rationale