Review the skin and mobility timeline and determine whether the pressure-injury prevention plan is effective.

Trend

Choose your responses, then check the answer.

Time	Data
Day 1	Sacral skin is intact and blanchable. The client requires extensive assistance to turn and has episodes of urinary incontinence.
Day 2	A persistent nonblanchable red area is warm and tender over the sacrum. Repositioning gaps of 4 to 5 hours are documented.
Day 3	The area is dark maroon, remains nonblanchable after pressure relief, and is more painful. Skin is still intact.

Q1. How should the nurse interpret the 3-day trend?

The skin findings show expected bruising from normal aging The prevention plan is effective because the skin remains intact Pressure-related tissue injury is worsening despite the current plan

Q2. Which change to the care plan is the priority?

Massage the maroon area vigorously and place a ring cushion under it Offload the area, individualize repositioning, add pressure redistribution, manage moisture, and reassess Avoid repositioning so the client can sleep without interruption

Q3. Which later finding would best indicate improvement?

Erythema and pain decrease after consistent offloading while the skin remains intact The area becomes black and firm but the client reports less sensation Repositioning is stopped because a specialty mattress is in use

Explanation

Persistent nonblanchable erythema followed by dark maroon discoloration, increasing pain, and missed repositioning indicates worsening pressure-related tissue injury rather than effective prevention. The nurse should immediately offload the area, reassess the skin and pain, individualize a repositioning plan to the client's tolerance, use an appropriate pressure-redistribution surface, manage moisture, and address nutrition and mobility. A support surface does not replace repositioning and skin assessment. Improvement would be decreasing erythema and pain with intact skin after consistent offloading; vigorous massage and ring-shaped devices can increase tissue stress.

Next question on this topicA nurse is caring for a 75-year-old client with limited mobility and urinary incontinence …From this question bank[전통+신유형] NCLEX LEVEL UP 패키지KRW 79,000

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