A client is immobile and has nonblanchable redness over the … | MyMerci
Mobility/ImmobilityBCC
Question
A client is immobile and has nonblanchable redness over the sacrum. Which intervention should the nurse implement?
1Massage the reddened area firmly every shift.
2Reposition the client and relieve pressure from the sacrum.✓ Correct answer
3Keep the head of bed at 90 degrees continuously.
4Apply heat directly to the reddened area.
Explanation
Nonblanchable redness indicates early pressure injury, and pressure must be relieved. Massage and heat can damage tissue. Keeping the head of bed high continuously can increase shear and pressure over the sacrum.
In-depth explanation
Clinical Judgment Use the client cues, timing, labs, and safety risks to select the response that best fits Sacral pressure injury prevention.
Memory Tip Match the strongest cue cluster to the safest nursing judgment.
KR vs US NCLEX items reward cue-based priority thinking rather than isolated recall.
Clinical scenario
Clinical Practice Guide For Sacral pressure injury prevention, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
Caution Do not choose an action from one isolated cue when the full scenario changes priority or safety.
Key concepts
Pressure Injury — Localized damage to skin or underlying tissue from pressure or shear.
Nonblanchable Redness — Redness that does not turn white with pressure and suggests tissue injury.
Repositioning — Changing body position to reduce pressure and improve comfort.