# A client is immobile and has nonblanchable redness over the sacrum. Which intervention should the nurse implement?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397179&lang=en  
> language: en  
> subject: Mobility/Immobility  
> category: BCC

## Question

A client is immobile and has nonblanchable redness over the sacrum. Which intervention should the nurse implement?

## Option

1. Massage the reddened area firmly every shift.
2. Reposition the client and relieve pressure from the sacrum. **✔ Correct answer**
3. Keep the head of bed at 90 degrees continuously.
4. Apply heat directly to the reddened area.

**Correct answer: 2**

## Explanation

Nonblanchable redness indicates early pressure injury, and pressure must be relieved. Massage and heat can damage tissue. Keeping the head of bed high continuously can increase shear and pressure over the sacrum.

## In-depth explanation

Clinical Judgment
Use the client cues, timing, labs, and safety risks to select the response that best fits Sacral pressure injury prevention.

Memory Tip
Match the strongest cue cluster to the safest nursing judgment.

KR vs US
NCLEX items reward cue-based priority thinking rather than isolated recall.

## Clinical scenario

Clinical Practice Guide
For Sacral pressure injury prevention, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.

Caution
Do not choose an action from one isolated cue when the full scenario changes priority or safety.

## Key concepts

- **Pressure Injury** — Localized damage to skin or underlying tissue from pressure or shear.
- **Nonblanchable Redness** — Redness that does not turn white with pressure and suggests tissue injury.
- **Repositioning** — Changing body position to reduce pressure and improve comfort.

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