A nurse is assisting with the care of a client who has impaired mobility. The client is admitted to the rehabilitation unit following a hip arthroplasty. The client has limited mobility and requires assistance to turn and transfer out of bed. Nurses Notes: Client is alert and oriented. Voided 400 mL of clear yellow urine into a bed pan. Hip dressing is dry and intact. Abdomen soft, nondistended, bowel sounds hypoactive. Which words accurately complete this sentence: The client is at highest risk for developing dropdownas evidenced by the client'sdropdown.

Rationale for correct choices • Pressure injury: Clients with impaired mobility, such as after hip arthroplasty, are at high risk for pressure injuries due to prolonged pressure on bony prominences like the sacrum, heels, and hips. Immobility reduces perfusion to the skin and underlying tissues, increasing the likelihood of ischemia and tissue breakdown. Even with intact skin on initial assessment, continuous monitoring and preventive interventions such as repositioning are essential. • Limited mobility: The client’s need for assistance with turning and transferring demonstrates limited mobility, which is a primary contributing factor to pressure injury development. Inability to reposition independently results in sustained pressure on skin areas, particularly over bony prominences. Documenting limited mobility provides objective evidence linking the client’s risk factor to potential pressure injury formation. Rationale for incorrect choices • Urinary tract infection: While immobility may contribute indirectly to urinary stasis, the client voided an adequate volume of clear urine, and there are no signs of infection such as dysuria, frequency, or fever. Therefore, a urinary tract infection is not the highest immediate risk for this client. • Bowel sounds: Hypoactive bowel sounds indicate decreased gastrointestinal motility, which may require monitoring but are not directly linked to the immediate risk of pressure injuries. They are not the primary factor in this client’s highest-risk condition. • Urine color: The client’s urine is clear yellow, indicating adequate hydration and normal urine characteristics. Urine color does not indicate a risk factor for pressure injury or other acute complications. • Urinary stasis: Although urinary stasis can occur in immobile clients, the current assessment shows adequate voiding without retention. Urinary stasis is not the most immediate concern compared with the risk for pressure injury. • Neuro status: The client is alert and oriented, showing no neurological impairment. Neuro status does not contribute to the immediate risk of pressure injury in this scenario. • Joint contracture: Joint contractures can develop over time with prolonged immobility, but the client’s risk for pressure injuries is more immediate and acute. Joint contractures are a longer-term complication and not the highest immediate risk.