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    Ati vati adult med surgical proctored exam

    A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan?

    Explanation & Rationale

    Rationale: A. Maintain the head of the bed greater than 45°: Elevating the head of the bed beyond 30° increases pressure and shear forces on the sacrum, contributing to skin breakdown. The bed should be maintained at the lowest elevation necessary to reduce pressure injury risk. B. Place a donut-shaped cushion under the client’s sacrum: Donut-shaped cushions can impede blood flow and concentrate pressure on surrounding tissues, increasing the risk of pressure injuries rather than preventing them. Specialty foam or gel cushions are preferred for pressure redistribution. C. Massage bony prominences three times daily: Massaging over bony areas is contraindicated as it may cause further tissue damage in areas already at risk for pressure injury. Prevention strategies focus on pressure relief, skin protection, and improved circulation without direct trauma. D. Apply moisturizer to damp skin after bathing: Applying moisturizer to slightly damp skin helps retain moisture, prevents dryness and cracking, and maintains skin integrity. This is an evidence-based practice in pressure injury prevention, especially for clients with fragile or at-risk skin.

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