A nurse updates a pressure-injury prevention plan for a client with limited mobility. For each cue or action, select the best classification.
Matrix
Choose your responses, then check the answer.
Explanation
Limited mobility, moisture, poor nutrition, and reduced perfusion increase tissue vulnerability and require an individualized plan. Prevention includes a support surface plus repositioning based on activity, skin tolerance, comfort, clinical condition, and goals; a mattress does not replace reassessment. Persistent color, temperature, consistency, or pain changes over pressure points may represent early tissue injury and require offloading and prompt plan reassessment.
Correct Answer Two rows identify risk factors, two are evidence-based prevention actions, and two are early tissue-injury cues requiring reassessment.
Why It Fits Each row tests a different decision: what increases susceptibility, what redistributes pressure or supports the skin, and what indicates current tissue change.
Clinical Picture Poor perfusion and moisture reduce tolerance. Repositioning intervals are individualized and skin is inspected during turns. Nonblanching or boggy painful tissue is not merely future risk.
Memory Link Risk predicts; prevention protects; tissue change prompts reassessment.
NCLEX Rule Do not let a support surface replace individualized repositioning or skin assessment.
Why the Alternatives Fail Risk factors do not by themselves prove injury. Prevention actions are proactive, while persistent tissue change requires immediate offloading and escalation of the plan.
Sources
12026 International Guideline: Skin and Tissue Assessment
22026 International Guideline: Repositioning and Mobilization
32026 NCLEX-RN Test Plan
The client needs help turning, has urinary incontinence, eats less than half of meals, and has reduced lower-extremity perfusion. The nurse combines risk reduction with repeated skin and tissue assessment.
Pressure redistribution — Use of repositioning and support surfaces to reduce the magnitude or duration of tissue loading.
Nonblanchable change — Persistent skin color change that does not fade with pressure release and can indicate early pressure injury.