# The wound-care nurse audits care for an immobile client at high risk for pressure injury. Which actions require follow-up? Highlight the actions that increase tissue injury risk.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=495007&lang=en  
> language: en  
> subject: Mobility/Immobility  
> category: BCC

## Question

The wound-care nurse audits care for an immobile client at high risk for pressure injury. Which actions require follow-up? Highlight the actions that increase tissue injury risk.

| Care area | Observed action |
| --- | --- |
| Surface | Uses a pressure-redistributing mattress matched to client risk |
| Skin | Massages persistent nonblanching redness over the sacrum |
| Position | Repositions the client using an individualized schedule |
| Support | Places a ring-shaped cushion directly under the sacrum |
| Moisture | Applies a moisture barrier after prompt incontinence care |
| Transfer | Drags the client upward in bed without a lift sheet |
| Heels | Floats both heels so they remain free of the mattress |
| Assessment | Inspects skin and pressure points during each care interval |
| Hygiene | Leaves a wet brief in place until the next scheduled round |

## Explanation

Massaging nonblanching redness, using a ring cushion, dragging the client, and leaving wet briefs in place require follow-up. These actions increase pressure, shear, friction, or moisture injury.

## In-depth explanation

Quick answer
Highlight massaging persistent sacral redness, placing a ring cushion under the sacrum, dragging the client up in bed, and leaving a wet brief until scheduled rounds. Each action increases local tissue stress or moisture damage.

Why this is correct
Pressure limits blood flow, while friction and shear distort tissue and moisture weakens the skin barrier. Prevention therefore redistributes load, offloads vulnerable areas, repositions without dragging, inspects skin, and manages incontinence promptly. Persistent redness is protected and assessed rather than massaged.[2][3]

Easy analogy or mental picture
Picture skin as fabric over padding. A heavy object compresses it, dragging pulls its layers in different directions, and moisture weakens the fabric. The picture explains combined forces but not pressure-injury staging.

Memory hook
Unload pressure, avoid dragging, keep skin dry, and inspect often.

NCLEX decision rule
When a client cannot reposition independently, look for pressure redistribution, heel offloading, safe lifting, individualized repositioning, skin checks, and prompt moisture care. Follow up on rings, massage over injured tissue, dragging, or delayed hygiene.

Why the other choices are wrong
A pressure-redistributing surface, scheduled repositioning, moisture barrier, floating the heels, and routine skin inspection reduce rather than increase the displayed tissue injury risks.References

- [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing

- [2]AHRQ: Best Practices in Pressure Injury PreventionAgency for Healthcare Research and Quality

- [3]NPIAP: Standardized Pressure Injury Prevention Protocol 2.0National Pressure Injury Advisory Panel

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