# An immobile client is at high risk for a hospital-acquired pressure injury. Complete the individualized prevention plan.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=547045&lang=en  
> language: en  
> subject: Mobility/Immobility  
> category: BCC

## Question

An immobile client is at high risk for a hospital-acquired pressure injury. Complete the individualized prevention plan.

The nurse should first ::선택::complete and document a skin and pressure-injury risk assessmentmassage the reddened sacrumwait for an open wound before actingapply powder without assessing moisture, then ::선택::keep the client in one comfortable positionplace a ring cushion beneath the sacrumuse an individualized repositioning plan and offload both heelselevate only the head of the bed. The prevention bundle should also ::선택::replace all turning with a specialty mattressmanage moisture, mobility, nutrition, and pressure-redistributing supportlimit protein and fluid for every clientcover blanchable erythema with a heating pad, and the nurse must ::선택::avoid documenting skin changesuse a fixed schedule without considering tolerancestop inspection after the first interventionreassess skin, comfort, and effectiveness and revise the plan.

## Explanation

Pressure-injury prevention requires a bundle tailored to the client's risks. The nurse should document a comprehensive skin and risk assessment, create an individualized repositioning schedule, offload the heels, manage moisture, support mobility and nutrition, and use an appropriate pressure-redistributing surface. Blanchable erythema is an early warning that should prompt pressure relief and reassessment rather than massage over a threatened bony prominence. A support surface does not replace turning, skin inspection, or attention to comfort and medical stability.

## In-depth explanation

Correct Answer
Assess risk and skin, reposition and offload, manage moisture and nutrition, use an appropriate surface, and reassess the response.

Why It Fits
Immobility, moisture, poor intake, sacral redness, and heel pressure create multiple simultaneous injury pathways.

Clinical Picture
The schedule must be individualized because tolerance, perfusion, pain, support surface, and clinical condition affect safe repositioning frequency.

Memory Link
Skin, shift, surface, dryness, diet, and recheck.

NCLEX Rule
Use a documented multidisciplinary prevention bundle rather than relying on one device or a fixed turning interval alone.

Why the Alternatives Fail
Massaging reddened tissue, leaving heels on the mattress, or using a surface without repositioning can worsen pressure-related damage.

Sources
1AHRQ Pressure Injury Prevention in Hospitals Training Program
2AHRQ Preventing Pressure Ulcers in Hospitals Toolkit
3NCSBN 2026 NCLEX-RN Test Plan

## Clinical scenario

Medical unit
An older adult is unable to reposition independently after a stroke. The client has moisture-associated skin exposure, reduced oral intake, blanchable sacral erythema, and heels resting directly on the mattress. No open injury is present.

## Key concepts

- **Pressure injury** — Localized damage to skin or underlying tissue caused by pressure or pressure combined with shear.
- **Heel offloading** — Positioning that removes direct pressure from the heel by supporting the lower leg appropriately.
- **Pressure-redistributing surface** — A mattress or overlay designed to spread load and reduce sustained pressure on vulnerable tissue.

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