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    Ati 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 is incorrect because hot water can further damage the skin and increase the risk of pressure injury. Lukewarm water and gentle cleansing are recommended. B. Provide the client with high-protein meals is correct. Protein is essential for tissue repair and healing. Adequate nutrition, particularly protein, supports skin integrity and helps prevent progression of pressure injuries in clients who are immobile. C. Place the client in a supine position is incorrect because prolonged pressure on bony prominences like the scapulae can worsen skin breakdown. The nurse should reposition the client frequently to relieve pressure. D. Gently massage the reddened areas is incorrect because massaging over reddened or affected areas can damage underlying tissues and worsen pressure injuries. Instead, the nurse should relieve pressure and protect the area.

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