# A bedbound client has nonblanchable redness over the sacrum and poor oral intake. Which nursing intervention is most appropriate to include in the care plan?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393671&lang=en  
> language: en  
> subject: Mobility/Immobility  
> category: BCC

## Question

A bedbound client has nonblanchable redness over the sacrum and poor oral intake. Which nursing intervention is most appropriate to include in the care plan?

## Option

1. Massage the reddened sacral area every shift.
2. Reposition the client on a schedule and offload pressure from the sacrum. **✔ Correct answer**
3. Keep the head of the bed at 60 degrees to improve nutrition.
4. Apply heat to the sacrum before hygiene care.

**Correct answer: 2**

## Explanation

Nonblanchable redness indicates a pressure injury risk or early pressure injury. Scheduled repositioning, pressure offloading, skin protection, and nutrition support reduce progression. Massaging reddened tissue, high head-of-bed positioning, or heat can worsen tissue injury or shear.

## In-depth explanation

Clinical Judgment
For pressure injury prevention, remove pressure and shear before focusing on comfort measures.

Memory Tip
Red sacrum: do not rub; turn, offload, protect, nourish.

KR vs US
NCLEX prioritizes prevention bundles and avoids outdated massage of reddened skin.

## Clinical scenario

Clinical Practice Guide
AHRQ pressure injury prevention materials emphasize best practices such as frequent repositioning and addressing nutrition risks.

Caution
Nonblanchable redness should be treated as a warning sign, not as normal skin irritation.

## Key concepts

- **Pressure Injury** — Localized injury to skin or underlying tissue related to pressure, shear, or device pressure.
- **Offloading** — Removing or redistributing pressure away from vulnerable tissue to prevent injury.
- **Shear** — Force that occurs when skin stays in place while deeper tissues slide, often with high head-of-bed positioning.

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