An 85-year-old client is admitted to the orthopedic unit following a repair of a left hip fracture. Three days later, the nurse observes an area of nonblanchable redness on the client's sacrum. Which action by the nurse is the most appropriate?
Explanation & Rationale
A. Inform the provider that blood cultures are needed: Blood cultures are indicated when there is suspicion of systemic infection, such as fever, elevated WBC count, or sepsis. A nonblanchable red area is an early pressure injury, not an indication of bloodstream infection. B. Inform the charge nurse that this client requires a private room: A private room is not required for a pressure injury because it is not an infectious condition. The focus should instead be on implementing interventions to prevent progression of the skin breakdown. C. Inform the nurse manager that the client's family is dissatisfied with his care: While family concerns are important, this option does not address the immediate clinical issue of preventing further skin injury in the client. D. Inform the assistive personnel (AP) of the need to turn the client every two hours: Repositioning is the primary intervention to reduce pressure, restore blood flow, and prevent worsening of the pressure injury. Communicating this need to the AP ensures consistent preventive care.