To reduce pressure points that may lead to pressure ulcers, the nurse should:

Question

1. Position the client directly on the trochanter when side-lying
2. Use a donut device for the client when sitting up
3. Elevate the head of the bed as little as possible
4. Massage over the bony prominences

Answer 1

ANS: 3
Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer de-velopment from shearing forces. The client should not be positioned directly on the trochanter because this can create pressure over the bony prominence. Donut-shaped cushions are contrain-dicated because they reduce blood supply to the area, resulting in wider areas of ischemia. Bony prominences should not be massaged. Massaging reddened areas increases breaks in the capillar-ies in the underlying tissues and increases the risk for injury to underlying tissue and pressure ul-cer formation.