Difficulty: Medium
Average Score: 89%
Simulated
Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?
Correct answer
A
Rationale
The correct answer is A: Preventing the client from sliding in bed. Shearing force occurs when skin moves in one direction while the underlying tissues move in the opposite direction, leading to tissue damage. By preventing the client from sliding in bed, the nurse can minimize shearing force on the pressure injury. This can be achieved by using pillows, positioning devices, or ensuring the bed is at an appropriate angle. Choice B (Lubricating the area with skin cream) may provide moisture and prevent friction but does not directly address shearing force. Choice C (Improving the client's hydration) is important for overall skin health but does not specifically target shearing force. Choice D (Pulling the client up from under the arms) may actually increase shearing force on the pressure injury.