# A nurse updates a pressure-injury prevention plan for a client with limited mobility. For each cue or action, select the best classification.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=396210&lang=en  
> language: en  
> subject: Mobility/Immobility  
> category: BCC

## Question

A nurse updates a pressure-injury prevention plan for a client with limited mobility. For each cue or action, select the best classification.

|  | Risk factor requiring plan adjustment | Evidence-based prevention action | Early tissue injury requiring reassessment |
| --- | --- | --- | --- |
| Frequent urinary leakage leaves the sacral skin repeatedly moist despite cleansing |  |  |  |
| Reduced heel perfusion is accompanied by poor intake and inability to shift weight independently |  |  |  |
| Set an individualized turning schedule based on mobility, skin tolerance, comfort, and the support surface |  |  |  |
| Inspect visible pressure points during each turn and float the heels while maintaining alignment |  |  |  |
| A persistent darker area over the sacrum feels warmer and firmer than surrounding tissue after offloading |  |  |  |
| The intact heel is newly painful and boggy compared with the opposite heel |  |  |  |

## Explanation

Limited mobility, moisture, poor nutrition, and reduced perfusion increase tissue vulnerability and require an individualized plan. Prevention includes a support surface plus repositioning based on activity, skin tolerance, comfort, clinical condition, and goals; a mattress does not replace reassessment. Persistent color, temperature, consistency, or pain changes over pressure points may represent early tissue injury and require offloading and prompt plan reassessment.

## In-depth explanation

Correct Answer
Two rows identify risk factors, two are evidence-based prevention actions, and two are early tissue-injury cues requiring reassessment.

Why It Fits
Each row tests a different decision: what increases susceptibility, what redistributes pressure or supports the skin, and what indicates current tissue change.

Clinical Picture
Poor perfusion and moisture reduce tolerance. Repositioning intervals are individualized and skin is inspected during turns. Nonblanching or boggy painful tissue is not merely future risk.

Memory Link
Risk predicts; prevention protects; tissue change prompts reassessment.

NCLEX Rule
Do not let a support surface replace individualized repositioning or skin assessment.

Why the Alternatives Fail
Risk factors do not by themselves prove injury. Prevention actions are proactive, while persistent tissue change requires immediate offloading and escalation of the plan.

Sources
12026 International Guideline: Skin and Tissue Assessment
22026 International Guideline: Repositioning and Mobilization
32026 NCLEX-RN Test Plan

## Clinical scenario

The client needs help turning, has urinary incontinence, eats less than half of meals, and has reduced lower-extremity perfusion. The nurse combines risk reduction with repeated skin and tissue assessment.

## Key concepts

- **Pressure redistribution** — Use of repositioning and support surfaces to reduce the magnitude or duration of tissue loading.
- **Nonblanchable change** — Persistent skin color change that does not fade with pressure release and can indicate early pressure injury.

## Related questions

- [A nurse is caring for a 75-year-old client with limited mobility and urinary incontinence …](https://mymerci.kr/pages/nclex_q.php?qn_id=364219&lang=en)
- [Review the skin and mobility timeline and determine whether the pressure-injury prevention…](https://mymerci.kr/pages/nclex_q.php?qn_id=393512&lang=en)
- [A client with limited mobility has nonblanchable redness over the sacrum. Which interventi…](https://mymerci.kr/pages/nclex_q.php?qn_id=394100&lang=en)
- [Review the client's progressive-mobility timeline and determine how the nurse should advan…](https://mymerci.kr/pages/nclex_q.php?qn_id=395203&lang=en)
- [A bedbound client has nonblanchable redness over the sacrum. Which nursing intervention is…](https://mymerci.kr/pages/nclex_q.php?qn_id=396625&lang=en)
- [A drowsy client is receiving continuous gastric tube feeding. Which nursing action best re…](https://mymerci.kr/pages/nclex_q.php?qn_id=397179&lang=en)
- [A postoperative client with a new colostomy has several stoma appearances shown. Click the…](https://mymerci.kr/pages/nclex_q.php?qn_id=397552&lang=en)
- [The home-care nurse reviews a palliative-care visit. Which findings require immediate foll…](https://mymerci.kr/pages/nclex_q.php?qn_id=494055&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=396210&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=396210&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=396210&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=396210&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=396210&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._