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A nurse is assigned to care for a client who reportedly has no special skincare needs. However, upon assessment, the nurse observes reddened areas over bony prominences. What action should the nurse take?A. Document the finding and continue with routine careB. Apply a topical antibiotic ointment to the affected areasC. Conduct and document an emergency assessmentD. Perform and document a focused assessment of skin integrity

Question

A nurse is assigned to care for a client who reportedly has no special skincare needs. However, upon assessment, the nurse observes reddened areas over bony prominences. What action should the nurse take?A. Document the finding and continue with routine careB. Apply a topical antibiotic ointment to the affected areasC. Conduct and document an emergency assessmentD. Perform and document a focused assessment of skin integrity

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Solution

The nurse should perform and document a focused assessment of skin integrity. This is because the reddened areas over bony prominences could be an early sign of pressure ulcers. The nurse needs to further assess these areas, determine the cause, and develop an appropriate care plan. Routine care may not be sufficient if the client is beginning to develop pressure ulcers. Applying a topical antibiotic ointment is not appropriate at this stage because there is no indication of infection. An emergency assessment is not necessary because the situation is not life-threatening.

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