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    Hesi compass B exit proctored exam

    The nurse notices a reddened area on the coccyx of a client who is wheelchair bound. Which intervention should the nurse implement?

    Explanation & Rationale

    A. Encouraging the client to shift weight while sitting helps relieve pressure on the coccyx, improving circulation and preventing further skin breakdown — this is the best initial intervention. B. Asking the team leader to document findings delays immediate action to prevent worsening of the pressure injury. C. Providing a donut-shaped cushion is not recommended because it can cause uneven pressure distribution and increase tissue damage. D. Rewashing the site and applying a hydrocolloid patch may be appropriate for a stage 2 ulcer or open area, but for a reddened area (stage 1), the priority is pressure relief, not dressing application.

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