The nurse is contributing to the care plan of an immobile patient. What should the nurse recognize as increasing the patient's risk of developing a pressure ulcer on the heels? (Select all that apply.)

Question

a. Being obese
b. Turning every hour
c. Lying on wet linens
d. Impaired circulation
e. Elevating legs on pillows
f. Wearing oxygen at 2 L per nasal cannula

Answer 1

ANS: C, D
C. D. Pressure ulcers are caused by ischemia, which results from continuous pressure that reduces blood flow to the area. Those with impaired circulation are at greater risk of developing a pressure ulcer. Linens should be kept clean, dry, and wrinkle-free. A. Obesity does not necessarily increase the client's risk for developing a pressure ulcer on the heels. B. E. F. Turning every hour, elevating the legs on pillows, and using oxygen would not contribute to the development of pressure ulcers.