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    ATI Nur 213 Med Surg proctored Exam
    Select All That Apply

    Which interventions can reduce the incidence of pressure injuries in hospitalized clients? (Select all that apply)

    Explanation & Rationale

    Choice A reason: Frequent skin assessments allow early detection of pressure injury signs, such as non-blanchable redness or skin breakdown. By identifying at-risk areas like the sacrum or heels, nurses can implement preventive measures promptly. This reduces tissue ischemia from prolonged pressure, preventing progression to ulcers by ensuring timely intervention to protect skin integrity. Choice B reason: Frequent turning and positioning relieve pressure on bony prominences, reducing ischemia and tissue damage. Repositioning every 2 hours promotes blood flow, preventing prolonged compression of capillaries, which leads to hypoxia and necrosis. This is a cornerstone of pressure injury prevention, especially in immobile patients with limited tissue perfusion. Choice C reason: Optimizing nutrition ensures adequate protein and micronutrient intake, essential for tissue repair and maintenance. Malnutrition impairs collagen synthesis and immune function, increasing susceptibility to skin breakdown. Adequate caloric and protein intake supports skin integrity, reducing the risk of pressure injuries by enhancing tissue resilience and healing capacity. Choice D reason: Maintaining the head of the bed at a 45-degree angle increases shear forces on the sacrum and coccyx, potentially exacerbating pressure injury risk. While it may aid respiratory function, it does not directly prevent pressure injuries and may contribute to skin breakdown in immobile patients due to increased frictional forces. Choice E reason: Inspecting the sacrum for blanching is part of skin assessment but is not an intervention to reduce incidence. Blanching indicates intact capillary perfusion, but non-blanchable redness signals early damage. While useful for staging, it is a diagnostic step, not a preventive measure like repositioning or nutrition, which actively reduce pressure injury risk.

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