Fundamentals Question #39

Question

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

Answers

  1. Offering the patient 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 patient’s legs in a dangling position for comfort
    • Rationale:

Overview

Explanation

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

Learning Outcomes

Test Taking Tip

Video Rationale