Which of the following nursing documentation best reflects the observable assessment of skin breakdown on the heel of an African American client?
1. 2-cm area of scaly, dry skin located on the client's right heel.
2. 2-cm area of nonblanching erythema located on the client's right heel.
3. 2-cm area purplish blue in color surrounded by lighter-colored skin located on right heel.
4. 2-cm area of blanching erythema located on the client's right heel; entire foot warm to the touch.
Question 2
Which of the following interventions is mostly likely to minimize the cause of a pressure ulcer on the left buttock of a client who is comatose?
1. Turn and position the client at least every 2 hours.
2. Use a lift sheet when moving the client up in the bed.
3. Change wet, soiled clothing as promptly as it is detected.
4. Keep the head of the client's bed elevated to less than 30 degrees.
