A nurse is developing a plan of care for a client who is immobile and at risk for developing a pressure injury. Which of the following interventions should the nurse include in the plan?
Explanation & Rationale
Rationale: A. This option is correct because applying moisturizing lotion after bathing helps maintain skin integrity, prevents dryness and cracking, and reduces the risk of pressure injuries. Proper skin care is a key preventive measure for clients who are immobile. B. This option is incorrect because massaging bony prominences is not recommended; it can actually cause tissue damage and increase the risk of pressure injury. Instead, gentle repositioning and pressure-relief techniques should be used. C. This option is incorrect because maintaining the head of the bed at a 45° angle increases pressure on the sacral area, heightening the risk for pressure injuries. The head of the bed should generally be kept at 30° or less when possible to reduce shear and pressure on bony prominences. D. This option is incorrect because contact isolation is not a preventive measure for pressure injuries. It is used for clients with infectious conditions to prevent transmission, not for immobility-related skin protection.