easy · NCLEX-RN Basic Care and Comfort
The nurse finds nonblanchable redness over a client’s heel.
In this pressure injury prevention case, what is the best immediate action?
- Offload the heel, then assess and document it
- Continue direct heel pressure and reassess the finding next week
- Rub the reddened heel firmly until the skin becomes pale
- Cover the skin finding without assessing or documenting it
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