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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. Which of the following actions should the nurse take?

    Explanation & Rationale

    Rationale: A. Provide the client with high-protein meals: Adequate protein intake supports tissue repair and helps prevent pressure ulcer development in clients on prolonged bed rest. Protein is essential for collagen synthesis and maintaining skin integrity, which reduces the risk of breakdown over bony prominences that are susceptible to pressure injuries. B. Place the client in a supine position: Continuous supine positioning increases pressure on the sacrum, heels, and other bony prominences, which can worsen skin breakdown. Frequent repositioning and use of pressure-relieving devices are recommended to prevent or manage early signs of pressure injuries. C. Gently massage the reddened areas: Massaging areas of redness is not recommended because it can damage underlying tissue and increase the risk of skin breakdown. Reddened areas indicate early pressure injury, and gentle pressure relief without rubbing or friction is preferred. D. Use hot water when cleaning the client's skin: Hot water can strip natural oils from the skin, causing dryness and irritation, which increases susceptibility to breakdown. Lukewarm water and mild cleansers are recommended to maintain skin integrity and reduce the risk of pressure injuries.

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