The nurse is caring for a client with fluid volume excess who has edematous skin. Which of the following is an appropriate nursing consideration for this client?
A) Keep the client in the same position to avoid irritating the skin.
B) Elevate an edematous part to a position higher than the heart's level.
C) Limit mouth care to prevent the formation of ulcers.
D) Perform skin care at least every 4 hours.
B
Feedback:
The nurse should change the person's position frequently for maximum comfort and elevate an edematous body part, usually the feet and ankles, to a position higher than the heart's level to help alleviate the edema. The skin and mucous membranes of the client with a fluid imbalance are susceptible to breakdown, cracking, and infections. Therefore, the nurse should give the client good mouth and skin care at least every 2 hours.
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