NursingPlex
    Sign In
    RN Adult Medical Surgical 2023 Proctored Exam

    A nurse is performing a skin assessment for a client who has been on bed rest for 1 week. The nurse notes reddened areas on the client's scapulae. Which of the following actions should the nurse take?

    Explanation & Rationale

    A. Use hot water when cleaning the client's skin.: Hot water can damage fragile skin and increase the risk of pressure injuries. The nurse should use lukewarm water and gentle cleansing techniques to protect skin integrity. B. Provide the client with high-protein meals.: Adequate protein intake supports tissue repair and helps prevent progression of pressure injuries. Nutrition plays a critical role in maintaining skin health and promoting healing in clients at risk for skin breakdown. C. Place the client in a supine position.: Continuous supine positioning increases pressure on the scapulae and other bony prominences, which can worsen skin breakdown. Frequent repositioning is necessary to relieve pressure and promote circulation. D. Gently massage the reddened areas.: Massaging reddened areas can damage underlying tissue and worsen pressure injuries. The nurse should avoid direct pressure or massage on areas showing early signs of breakdown and instead use repositioning and protective devices.

    🔒 Submit your answer to reveal