# 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?

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> language: en  
> subject: NCLEX-RN  
> 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 reduce pressure on the sacrum.
4. Apply heat to the sacrum before hygiene care.

**Correct answer: 2**

## Explanation

Repositioning the client on a schedule and offloading pressure from the sacrum is correct because relieving sustained pressure is the priority action for nonblanchable redness, an early sign of pressure injury. Massaging the reddened area can worsen tissue damage and is contraindicated. Keeping the head of the bed elevated increases shear force on the sacrum, which accelerates skin breakdown rather than preventing it. Applying heat increases metabolic demand and risk of further tissue injury in an already compromised area.

## 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NCLEX prioritizes prevention bundles and avoids outdated massage of reddened skin.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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