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    Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph

    A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of non-blanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?

    Explanation & Rationale

    A. Assessing pressure points every 24 hours is insufficient. Skin should be assessed at least every shift or more often for high-risk clients. B. Shifting weight every 15 minutes while sitting helps relieve pressure and improve circulation, preventing further skin breakdown. This is essential for clients with paraplegia who are at high risk for pressure injuries. C. Turning every 3 hours is inadequate; repositioning should occur at least every 2 hours to prevent tissue ischemia. D. Donut-shaped cushions are not recommended because they concentrate pressure around the edges, worsening tissue damage.

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