A nurse is developing a plan of care for a client with traumatic injuries from a motor vehicle crash. Which nursing intervention does the nurse include in the plan of care to reduce the risk of integumentary complications?
A) Provide active or passive exercises at least once every 8 hours.
B) Encourage coughing, deep breathing, and incentive spirometry.
C) Assist the client in turning at least every 2 hours.
D) Assist the client in turning at least every 8 hours.
Answer: C
Assisting the client to turn at least every 2 hours is the most appropriate intervention for the nurse to include in the plan of care to reduce the risk of integumentary complications. Turning the client every 8 hours will not reduce the risk of integumentary complications. Encouraging exercise improves muscle tone, and encouraging coughing and deep breathing reduces the risk of respiratory complications, but neither helps reduce the risk of integumentary complications.
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