Question

When collecting data on a client who is immobile, a nurse locates a reddened area of skin on the left scapula. Which of the following actions should the nurse take?

A) Document the finding
B) Apply a heating pad
C) Massage the area
D) Turn and reposition the client

Answer 1

The nurse should document the findings and turn and reposition the client.

Step-by-step explanation:

When collecting data on a client who is immobile and discovers a reddened area of skin on the left scapula, the nurse should take the following action:

1. Document the findings: It is important for the nurse to accurately record and document any changes or abnormalities observed during the data collection process.
2. Turn and reposition the client: Reddened or discolored skin can indicate the presence of pressure ulcers or skin breakdown due to prolonged immobility. Turning and repositioning the client regularly helps relieve pressure on specific areas, preventing the development of pressure ulcers.

By documenting the findings and ensuring adequate repositioning, the nurse can monitor the client's skin health and take appropriate measures to prevent complications.