The nurse understands that a pressure ulcer is an impairment of the skin as a result of prolonged ischemia. One of the easiest ways to prevent a pressure ulcer from occurring in an immobile client is to:

Question

1. Keep the skin dry
2. Provide range of motion every shift
3. Use lift equipment when transferring a client
4. Turn the client a minimum of every 2 hours

Answer 1

ANS: 4
Implement a comprehensive skin care program to prevent skin breakdown in all clients, from ne-onates to older adults. Effective skin care programs include accurate and consistent assessment and documentation as well as interventions to protect the skin (e.g., turn the client at least every 2 hours). Keeping the skin dry is very important in preventing skin breakdown, range-of-motion exercises will help prevent contractures from occurring, lift equipment will help decrease harm to both clients and staff, but turning the client will best help prevent pressure ulcers.