# Review the skin and mobility timeline and determine whether the pressure-injury prevention plan is effective. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=568924&lang=en > language: en > subject: Mobility/Immobility > category: BCC ## Question Review the skin and mobility timeline and determine whether the pressure-injury prevention plan is effective. | Time | Data | | --- | --- | | Day 1 | Sacral skin is intact and blanchable. The client requires extensive assistance to turn and has episodes of urinary incontinence. | | Day 2 | A persistent nonblanchable red area is warm and tender over the sacrum. Repositioning gaps of 4 to 5 hours are documented. | | Day 3 | The area is dark maroon, remains nonblanchable after pressure relief, and is more painful. Skin is still intact. | Q1. How should the nurse interpret the 3-day trend? The skin findings show expected bruising from normal aging The prevention plan is effective because the skin remains intact Pressure-related tissue injury is worsening despite the current plan Q2. Which change to the care plan is the priority? Massage the maroon area vigorously and place a ring cushion under it Offload the area, individualize repositioning, add pressure redistribution, manage moisture, and reassess Avoid repositioning so the client can sleep without interruption Q3. Which later finding would best indicate improvement? Erythema and pain decrease after consistent offloading while the skin remains intact The area becomes black and firm but the client reports less sensation Repositioning is stopped because a specialty mattress is in use ## Explanation Persistent nonblanchable erythema followed by dark maroon discoloration, increasing pain, and missed repositioning indicates worsening pressure-related tissue injury rather than effective prevention. The nurse should immediately offload the area, reassess the skin and pain, individualize a repositioning plan to the client's tolerance, use an appropriate pressure-redistribution surface, manage moisture, and address nutrition and mobility. A support surface does not replace repositioning and skin assessment. Improvement would be decreasing erythema and pain with intact skin after consistent offloading; vigorous massage and ring-shaped devices can increase tissue stress. ## In-depth explanation Trend to recognize The sacral findings progress from risk to nonblanchable redness and then to dark maroon discoloration with increasing pain. Missed repositioning and ongoing moisture show that the prevention plan is failing. Priority response Offload the area now, reassess skin and pain, individualize repositioning, use a pressure-redistribution surface, control moisture, support nutrition, and evaluate the response. NCLEX decision rule A mattress assists the plan; it never replaces movement, inspection, moisture care, and reassessment. Why the alternatives fail Waiting for skin breakdown misses early tissue damage. Vigorous rubbing can worsen injury, and a ring-shaped device can concentrate pressure at its edge. A rigid schedule should be adjusted to risk, tolerance, and observed skin response. Source 1International Guideline: Repositioning 2International Guideline: Support Surfaces 3International Guideline: Preventive Skin Care 42026 NCLEX-RN Test Plan ## Clinical scenario Basic care and comfort An older adult with left-sided weakness after a stroke requires extensive help to reposition and has urinary incontinence. The nurse reviews skin findings and care delivery over 3 days. ## Key concepts - **advanced dementia** — Severe stage with profound cognitive and functional impairment; FAST 7 or MDS very high. - **careful hand feeding** — Assisted oral feeding emphasizing comfort over volume; preferred over PEG. - **Choosing Wisely** — Initiative identifying low-value or potentially harmful interventions. ## 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. 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