An immobile client is at high risk for a hospital-acquired pressure injury. Complete the individualized prevention plan.
Drop-down Cloze
Choose your responses, then check the answer.
Explanation
Pressure-injury prevention requires a bundle tailored to the client's risks. The nurse should document a comprehensive skin and risk assessment, create an individualized repositioning schedule, offload the heels, manage moisture, support mobility and nutrition, and use an appropriate pressure-redistributing surface. Blanchable erythema is an early warning that should prompt pressure relief and reassessment rather than massage over a threatened bony prominence. A support surface does not replace turning, skin inspection, or attention to comfort and medical stability.
Correct Answer Assess risk and skin, reposition and offload, manage moisture and nutrition, use an appropriate surface, and reassess the response.
Why It Fits Immobility, moisture, poor intake, sacral redness, and heel pressure create multiple simultaneous injury pathways.
Clinical Picture The schedule must be individualized because tolerance, perfusion, pain, support surface, and clinical condition affect safe repositioning frequency.
Memory Link Skin, shift, surface, dryness, diet, and recheck.
NCLEX Rule Use a documented multidisciplinary prevention bundle rather than relying on one device or a fixed turning interval alone.
Why the Alternatives Fail Massaging reddened tissue, leaving heels on the mattress, or using a surface without repositioning can worsen pressure-related damage.
Sources
1AHRQ Pressure Injury Prevention in Hospitals Training Program
2AHRQ Preventing Pressure Ulcers in Hospitals Toolkit
3NCSBN 2026 NCLEX-RN Test Plan
Medical unitAn older adult is unable to reposition independently after a stroke. The client has moisture-associated skin exposure, reduced oral intake, blanchable sacral erythema, and heels resting directly on the mattress. No open injury is present.
Pressure injury — Localized damage to skin or underlying tissue caused by pressure or pressure combined with shear.
Heel offloading — Positioning that removes direct pressure from the heel by supporting the lower leg appropriately.
Pressure-redistributing surface — A mattress or overlay designed to spread load and reduce sustained pressure on vulnerable tissue.