The nurse understands that in order to prevent pressure ulcer development, he must remove pressure from high-risk areas of the body. What nursing interventions are essential to accomplish this goal? Select all that apply

Question

1. Use pillows to offload pressure.
2. Turn the client at least every 2 hours.
3. Use a shoe or cast to prevent pressure.
4. Keep the client on bed rest.
5. Pull the client up in bed every 2 hours or less.

Answer 1

1. Use pillows to offload pressure.
2. Turn the client at least every 2 hours.
3. Use a shoe or cast to prevent pressure.

Rationale: Use pillows to offload pressure. Pillows provide a cushion for bony prominences, which decreases pressure. Turn the client at least every 2 hours. Turning takes prolonged pressure off a single area. Use a shoe or cast to prevent pressure. Shoes and properly padded casts protect high-risk areas from pressure by providing a barrier and a cushion. Keep the client on bed rest. This would be inappropriate, as activity and mobility prevent prolonged pressure in one area. Pull the client up in bed every 2 hours or less. Pulling clients up in bed increases friction and shear, but does not prevent pressure.