Difficulty: Medium
Average Score: 64%
Simulated
A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client's risk of developing a pressure injury?
Correct answer
A
Rationale
Correct Answer: A - Ensure the client's heels are not touching the mattress.
Rationale:
1. Pressure injuries commonly occur at bony prominences like heels.
2. When heels are in contact with the mattress for a prolonged period, it can lead to compromised blood flow and tissue damage.
3. Elevating the heels off the mattress reduces pressure and friction, decreasing the risk of pressure injury.
Summary of other choices:
B. Repositioning every 4 hr helps prevent pressure injuries but focusing on heel offloading is more critical.
C. Raising the head of the bed does not directly address the pressure on the heels.
D. Massaging bony prominences can actually increase the risk of pressure injury by causing friction and shearing forces.
Rationale:
1. Pressure injuries commonly occur at bony prominences like heels.
2. When heels are in contact with the mattress for a prolonged period, it can lead to compromised blood flow and tissue damage.
3. Elevating the heels off the mattress reduces pressure and friction, decreasing the risk of pressure injury.
Summary of other choices:
B. Repositioning every 4 hr helps prevent pressure injuries but focusing on heel offloading is more critical.
C. Raising the head of the bed does not directly address the pressure on the heels.
D. Massaging bony prominences can actually increase the risk of pressure injury by causing friction and shearing forces.