Which nursing intervention should be applied to a client with a nursing diagnosis of Risk for Skin Integrity Impairment related to immobility?
1. Encourage client to eat at least 40% of meals.
2. Keep linens dry and wrinkle-free.
3. Restrict fluid intake.
4. Turn client every 3 hours.
Correct Answer: 2
Rationale 1: For nutritional support to promote healthy tissue, clients should consume more than 40% of their meals.
Rationale 2: Keeping linens dry and wrinkle-free will prevent pressure areas.
Rationale 3: Fluids should not be restricted unless some other physical condition dictates. The skin should be kept hydrated.
Rationale 4: To relieve pressure, the client should be turned every 2 hours, not every 3.
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