Editing Fundamentals of Nursing – RN Practice Questions (section)

==Question 11==
The nurse observes assistive personnel providing morning care. Which observation requires the nurse to intervene?
# The assistive personnel washes the patient's eye from the inner canthus to the outer canthus.
# The assistive personnel returns the foreskin to its natural position after cleaning an uncircumcised patient.
# The assistive personnel briskly massages a reddened area over the patient's sacrum to stimulate circulation.
# The assistive personnel dries thoroughly between the patient's toes and applies lotion to the top of the foot.

'''Answer:''' 3. Massaging a reddened area over the sacrum.

''Rationale:'' Massage over a reddened bony prominence is contraindicated, because the underlying tissue is already damaged and friction plus shear can deepen the injury. The nurse must stop this immediately and reinforce correct pressure injury prevention. Option 1 is correct technique, which prevents transfer of organisms toward the lacrimal duct. Option 2 is essential, since failure to reduce the foreskin can cause paraphimosis and vascular compromise. Option 4 is correct, since moisture between the toes promotes maceration and fungal infection, while lotion elsewhere prevents cracking.