# A client with limited mobility has nonblanchable redness over the sacrum. Which intervention is most appropriate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394100&lang=en  
> language: en  
> subject: Mobility/Immobility  
> category: BCC

## Question

A client with limited mobility has nonblanchable redness over the sacrum. Which intervention is most appropriate?

## Option

1. Massage the reddened area vigorously each shift.
2. Place the client directly on the sacrum to reduce hip pressure.
3. Reposition the client regularly and use pressure-reducing support surfaces. **✔ Correct answer**
4. Apply adhesive tape tightly over the area to protect it.

**Correct answer: 3**

## Explanation

Nonblanchable redness suggests early pressure injury. Pressure should be relieved through repositioning, support surfaces, moisture control, nutrition support, and skin inspection. Massaging reddened tissue or applying tight tape can worsen injury.

## In-depth explanation

Clinical Judgment
Pressure injury prevention begins with removing pressure, not rubbing the damaged tissue.

Memory Tip
Red that does not blanch: offload pressure.

## Clinical scenario

Clinical Practice Guide
Skin integrity care includes turning schedules, pressure redistribution, moisture management, nutrition, and daily inspection.

Caution
Do not massage bony prominences with nonblanchable redness.

## Key concepts

- **Pressure Injury** — Localized skin or tissue damage caused by pressure or shear.
- **Nonblanchable Redness** — Redness that does not turn white with pressure and suggests tissue injury.
- **Offloading** — Removing pressure from an at-risk area.

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