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    Ati rn comprehensive predictor 2023 proctored exam

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

    Explanation & Rationale

    Rationale: A. Place the client upright on a donut-shaped cushion: Donut-shaped cushions are not recommended because they create uneven pressure distribution, which can worsen ischemia around pressure points rather than relieve it, potentially delaying healing. B. Teach the client to shift his weight every 15 min while sitting: Frequent weight shifting relieves pressure on the ischial area and promotes circulation, helping to prevent progression of a stage 1 pressure injury. This intervention supports client independence and tissue integrity. C. Assess pressure points every 24 hr: Pressure points should be assessed more frequently than once daily, especially in high-risk clients. Routine skin assessments at least once per shift are critical for early detection of pressure injury progression. D. Turn and reposition the client every 3 hr while in bed: The standard recommendation is to reposition immobile clients at least every 2 hours in bed to redistribute pressure and reduce the risk of further skin breakdown. Extending intervals increases risk of injury.

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