The wound-care nurse audits care for an immobile client at high risk for pressure injury. Which actions require follow-up? Highlight the actions that increase tissue injury risk.
Highlight in Table
Choose your responses, then check the answer.
Explanation
Massaging nonblanching redness, using a ring cushion, dragging the client, and leaving wet briefs in place require follow-up. These actions increase pressure, shear, friction, or moisture injury.
Quick answer Highlight massaging persistent sacral redness, placing a ring cushion under the sacrum, dragging the client up in bed, and leaving a wet brief until scheduled rounds. Each action increases local tissue stress or moisture damage.
Why this is correct Pressure limits blood flow, while friction and shear distort tissue and moisture weakens the skin barrier. Prevention therefore redistributes load, offloads vulnerable areas, repositions without dragging, inspects skin, and manages incontinence promptly. Persistent redness is protected and assessed rather than massaged.[2][3]
Easy analogy or mental picture Picture skin as fabric over padding. A heavy object compresses it, dragging pulls its layers in different directions, and moisture weakens the fabric. The picture explains combined forces but not pressure-injury staging.
NCLEX decision rule When a client cannot reposition independently, look for pressure redistribution, heel offloading, safe lifting, individualized repositioning, skin checks, and prompt moisture care. Follow up on rings, massage over injured tissue, dragging, or delayed hygiene.
Why the other choices are wrong A pressure-redistributing surface, scheduled repositioning, moisture barrier, floating the heels, and routine skin inspection reduce rather than increase the displayed tissue injury risks.
References
[1]
NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing
[2]
AHRQ: Best Practices in Pressure Injury PreventionAgency for Healthcare Research and Quality