32-Skin integrity and Wound care

The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Which term best describes this complication?

evisceration Explanation: Evisceration is the protrusion of viscera through an abdominal wound opening. Evisceration can follow dehiscence if the opening extends deeply enough to allow the abdominal fascia to separate and internal organs to protrude.

The nurse is caring for a client in the emergency department with a cut sustained 15 minutes ago while the client was preparing dinner at home. The nurse understands that the wound is in which phase of healing?

hemostasis phase Explanation: Hemostasis is the initial phase after an injury. Hemostasis stimulates other cells to come to the wound to begin other phases of wound healing. The inflammatory phase follows hemostasis; white blood cells move into the wound to remove debris and release growth factors. The proliferation phase is the regenerative phase, in which granulation tissue is formed. The maturation phase involves collagen remodeling.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding?

As a stage I pressure injury Explanation: Stage I pressure injuries are characterized by intact but reddened skin that is nonblanchable. Therefore, the nurse categorizes and documents this pressure injury as stage I. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue. Stage IV exposes muscle and bone. Therefore, the nurse does not categorize this pressure injury as stage II, III, or IV.

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

Desiccation Explanation: Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time?

Discontinue the therapy and assess the client. Explanation: The best action by the nurse at this time is to discontinue the therapy and assess the client; this should be done before notifying the health care provider or documenting the event. Gently rubbing the area or massaging it would not be appropriate at this time.

A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply.

Fingers with quick capillary refill Warm hand No finger numbness or tingling Explanation: The nurse should monitor, observe, and document for quick capillary refill of fingers, normal radial pulse, normal skin color, no swelling, numbness, and tingling of the hand and fingers. Cyanosis, pallor, coolness, numbness, tingling, swelling, or absent or diminished pulse are signs that circulation may be decreased or that nerve function is impaired.

The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective?

"I will put a layer of cloth between my skin and the ice pack." Explanation: Teaching has been effective when the client understands that a layer of cloth is needed between the ice pack and skin to preserve skin integrity. The ice pack should be removed if the skin becomes mottled or numb; this indicates that the cold therapy is too cold. The ice pack can be in place for no more than 20-30 minutes at a time, and a minimum of 30 minutes should go by before it is reapplied.

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?

"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." Explanation: The bulb-like drain allows removal of blood and drainage from the surgical wound. All the statements are factual and true; however, the name of the drain, how it works, when it will be removed, and measurement of the exudate are drain management skills and knowledge. Only, "the drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound" answers the clients question about why the drain is present.

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?

"Your wound will heal slowly as granulation tissue forms and fills the wound." Explanation: This statement is correct, because it provides education to the client: "Your wound will heal slowly as granulation tissue forms and fills the wound." Large wounds with extensive tissue loss may not be able to be closed by primary intention, which is surgical intervention. Secondary intention, in which the wound is left open and closes naturally, is not done if less of a scar is necessary. Third intention is when a wound is left open for a few days and then, if there is no indication of infection, closed by a surgeon.

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true?

A Penrose drain promotes passive drainage into a dressing. Explanation: A Penrose drain is an open drainage system that promotes passive drainage of fluid into a dressing. The Jackson-Pratt drain has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure.

What should the nurse assess before application of sitz bath therapy? Select all that apply.

Client's ability to ambulate to the bathroom Client's ability to sit for 15 to 20 minutes Client's perineal/rectal area Client's need to void Explanation: Before application of sitz bath therapy, the nurse should assess the client's ability to ambulate to the bathroom; ability to sit for 15 to 20 minutes; appearance of the perineal/rectal area for swelling, drainage, tenderness; and the client's bladder fullness and need to void. Electrolyte levels are not affected by sitz bath therapy.

Which is not considered a skin appendage?

Connective tissue Explanation: Hair, the sebaceous gland, and eccrine sweat glands are skin appendages that are formed with the enfolding of the epidermis into the dermis. The dermis is composed of connective tissue.

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?

Dehiscence of the wound Explanation: Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound. Manifestations of infection include redness, warmth, swelling, and heat. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings?

Diffuse dermatitis accompanied by pruritus Explanation: The external or internal irritants can cause skin reactions. The irritants may be chemical, such as poison ivy. Dermatitis, an inflammation of the skin, most often produces epidermal and dermal damage or irritation, possibly accompanied by pain, itching, redness, and blisters; pruritus is itching. A contusion is a closed wound with bleeding in underlying tissues from a blunt blow. Fungal infections do not cause a rash or itching. An abscess is a localized collection of white blood cells and cellular debris (pus) that appears swollen and inflamed.

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?

Fish Explanation: To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing. Pasta salad has a high carbohydrate amount with no protein. Banana has a high amount of vitamin C but no protein. Green beans have some protein but not as much as fish.

A nurse is providing wound care for a client who has a pressure injury on the right buttock. Place in order the nursing interventions the nurse should perform during this dressing change. Use all options.

Give pain medication. Use nonsterile gloves. Remove old dressing. Apply sterile gloves. Cleanse the wound with normal saline. Apply wound covering. Explanation: The correct order for this dressing change is giving pain medication, applying nonsterile gloves to remove old dressing, removing old dressing, applying sterile gloves, cleansing the wound with normal saline, and applying a wound covering.

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?

Keep the swab and the inside of the culture tube sterile. Explanation: The swab and the inside of the culture tube should be kept sterile. The wound should be cleansed prior to obtaining the culture. The culture swab should not touch the skin surrounding the wound site. In addition, if multiple sites have to be cultured then separate culture swabs should be used.

When applying an external heating pad, which prescription from the health care provider would the nurse question?

Leave heating pad on for 40 to 45 minutes, then off for 2 hours. Explanation: The nurse should question the prescription to leave the heating pad on for 40 to 45 minutes, because this is too long and could cause a rebound phenomenon. Using heat for more than 20 to 30 minutes can result in tissue congestion, vasoconstriction, and increases the risk of tissue damage. All other prescriptions are recommended guidelines for use of a heating pad.

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?

Rotate the swab several times over the wound surface to obtain an adequate specimen. Explanation: The nurse should press and rotate the swab several times over the wound surface. The swab should be inserted into the culture tube at the bedside, immediately after collection. Saline or any other fluid is not added to the tube and anesthetics are not applied prior to collection.

A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action?

Stop removing staples and inform the surgeon Explanation: If there are signs of dehiscence, the nurse should stop removing staples and inform the surgeon. The surgeon may or may not order further staple removal. An occlusive dressing or ABD pad will not adequately prevent further dehiscence.

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage?

Supports the area around the wound Explanation: Bandages and binders are used to secure dressings, apply pressure, and support the wound. A roller bandage is a continuous strip of material wrapped on itself to form a cylinder or roll and is applied using a circular turn, spiral turn, or figure-of-eight turn. It is effective for use around joints, such as the knee, elbow, ankle, and wrist.

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

TRUE

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?

The status of the client's tetanus immunization Explanation: Staging the wound is only done with pressure injuries. The presence of dirt or debris is something that will need to be addressed, but not the most important assessment. Understanding how the client stepped on the nail will need to be noted and is a possible educational opportunity for prevention, but it is not the most important assessment concern. Tetanus is caused by the Clostridium bacteria that can enter the body through a deep injury like stepping on a nail. The tetanus vaccine booster should be given every 10 years and is the best defense against developing the tetanus illness. Tetanus is a concern because it is a painful medical emergency that could lead to death. So, finding out the status of the client's tetanus immunization is the most important assessment information the nurse can collect from the client.

A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess?

The wound is 3 × 5 cm, with yellow tissue covering the entire wound. Explanation: The wound with yellow tissue covering the entire wound is unstageable. The depth of the wound cannot be determined, because it is covered entirely with slough. A stage III wound will have subcutaneous tissue visible. A stage IV wound will have tendon, muscle, or bone exposed. A suspected deep tissue injury presents as a maroon or purple lesion or blood-filled blister.

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn?

Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown Explanation: Second-degree burns are moderate to deep partial-thickness burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. First-degree burns are superficial and may be pinkish or red with no blistering. Third-degree burns are full-thickness burns and may vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery.

A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow." Based on this classification, which nursing action should the nurse perform?

Wound irrigation Explanation: With the yellow classification using the RYB wound classification system, wound irrigation should be implemented. Yellow wounds require wound cleaning and irrigation related to exudate and slough. Gentle cleansing and moist dressings are utilized in the Red classification. Debridement is required for the wounds in the Black classification because the wounds have necrotic tissue present.

The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately?

a sterile, flexible applicator moistened with saline Explanation: A sterile, flexible applicator is the safest implement to use. A small plastic ruler is not sterile. A sterile tongue blade lubricated with water soluble gel is too large to use in a wound bed. An otic curette is a surgical instrument designed for scraping or debriding biological tissue or debris in a biopsy, excision, or cleaning procedure and not flexible.

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes Explanation: Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process. This is a greater risk factor for impaired healing than are smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process. Short-term lack of food intake is not as significant as longer-term lack of nutrition.

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?

applying sterile dressings with normal saline over the protruding organs and tissue Explanation: The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.

When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding?

incision Explanation: An incision is a clean separation of skin and tissue with smooth, even edges. Therefore the nurse documents the finding as an incision. In an avulsion, large areas of skin and underlying tissue have been stripped away. An abrasion involves the stripping of the surface layers of skin. A laceration is a separation of skin and tissue with torn, irregular edges. Therefore the nurse does not document the finding as an avulsion, abrasion, or laceration.

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

removing dead or infected tissue to promote wound healing Explanation: Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration.

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage?

serosanguineous Explanation: This describes serosanguineous wound drainage. Drainage that is pale yellow, watery, and like the fluid from a blister is called serous. Drainage that is bloody is called sanguineous. Drainage that contains white cells and microorganisms is called purulent.

A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which statement indicates that the client understands?

"I will squeeze the chamber and apply the cap to maintain negative pressure." Explanation: The Hemovac drain chamber should be squeezed and the cap applied to maintain negative pressure. The negative pressure pulls the drainage into the collection chamber. This negative pressure must be maintained continuously unless the drain is being emptied. The drain must be checked and emptied at least every 4 hours. A Penrose drain has gauze at the end of the drain to catch drainage.

A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics?

An infant's skin and mucous membranes are easily injured and at risk for infection. Explanation: An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thinner and weaker than in adults. The structure of the skin changes as a person ages. A child's skin becomes more resistant to injury and infection as the child grows.

A nurse is caring for a client who has a pressure injury on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document?

Black classification Explanation: A wound that requires debridement would be classified in the black category. The red classification would indicate dressing changes for treatment. The yellow classification would indicate cleansing of the wound related to the drainage or slough in the wound. Unstageable is not a classification in the RYB Wound Classification System.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

Clean the wound from the top to the bottom and from the center to outside. Explanation: Using sterile technique, clean the wound from the top to the bottom and from the center to the outside. Dry the area with a gauze sponge, not an absorbent cloth.

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?

transparent Explanation: The nurse should use a transparent dressing to cover the IV insertion site, because such dressings allow the nurse to assess a wound without removing the dressing. In addition, they are less bulky than gauze dressings and do not require tape, since they consist of a single sheet of adhesive material. Gauze dressing is ideal for covering fresh wounds that are likely to bleed or wounds that exude drainage. A hydrocolloid dressing helps keep the wound moist. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.

The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include?

"It provides a way to remove drainage and blood from the surgical wound." Explanation: The bulb-like drain allows removal of blood and drainage from the surgical site. It does not provide a route for medication administration or decrease the chance for infection, nor does it stay attached permanently.

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?

"Very little scar tissue will form." Explanation: Very little scar tissue is expected to form in a minor surgical wound. Second-intention healing involves a complex reparative process in which the margins of the wound are not in direct contact. Third-intention healing takes place when the wound edges are intentionally left widely separated and later brought together for closure.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

Assess the client's wound and vital signs. Explanation: First, the nurse should assess the client. The nurse needs to assess the wound, assess if the therapy is working properly, assess the client's vital signs, and assess the pain. The other options might be appropriate but only after the client has been assessed.

Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply.

Clean the wound from top to bottom. Use a sterile applicator to apply any ointment that is ordered. Use a new gauze for each wipe of the wound. Avoid touching the wound bed, whether with gloves or forceps. Explanation: Wounds should be cleansed from top to bottom and from the center to the outside using a new gauze for each wipe. A sterile applicator may be used to apply antiseptic ointment, if ordered, and the nurse should avoid touching the wound bed with gloves or forceps.

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?

Stage II Explanation: A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater. A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Injuries at this stage may include undermining and tunneling. Stage IV injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces?

a client sitting in a chair who slides down Explanation: Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure ulcer from shearing forces would be a client sitting in a chair who slides down.

The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present?

stage II Explanation: The area of redness and blister formation indicate that the client is experiencing a stage II pressure injury. A stage I pressure injury is intact but reddened. A stage III pressure injury has a shallow skin crater that extends to the subcutaneous tissue. A stage IV pressure injury is severe; the tissue is deeply ulcerated and exposes muscle and bone with the presence of necrotic tissue likely.

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. Explanation: If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing the sutures; soap is not used for this purpose. Picking at the sutures could cause pain and bleeding. Crusting does not necessarily indicate inadequate wound healing.

A client limps into the emergency department and states, "I stepped on a nail and did not have shoes on. Now I can barely walk." What types of concern does the nurse anticipate the client will have?

Tetanus, infection, wound care, and pain control Explanation: Chances are the client knows that stepping on a nail could lead to a serious complication or illness, even if the client cannot remember or does not know about tetanus or infections. How to care for the wound is usually something clients will want to know before being discharged. The client in this scenario is reporting pain, so pain control will be one of the concerns. It is unlikely that the client will be worried about scarring on the bottom of the foot or sutures due to it being a puncture. The client is still walking, although in pain and with a limp, it would be unlikely the client would be concerned about being able to walk. More than likely, the client has already figured out the injury may not have occurred or would not be as bad had he or she been wearing shoes, so the nurse would not anticipate the need for preventative education.

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?

The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly. Explanation: The nurse would keep the heating pad in place for 20 to 30 minutes, assessing it regularly. The nurse would not use a safety pin to attach the pad to the bedding. The pin could create problems with this electric device. The nurse would not place the heating pad directly under the client's neck. The nurse would not cover the heating pad with a heavy blanket.

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?

"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." Explanation: The nurse should apply any topical medications, foams, gels, and/or gauze to the wound as prescribed; ensuring that the product stays confined to the wound and does not impact on intact surrounding tissue/skin. Applying the medicated gel with an applicator allows for better control over the application, thus minimizing any additional trauma to wound. The procedure should be preformed using sterile technique, but clean technique can be used when proving care to chronic or pressure injury wounds. To manage contamination risk, cleansing of a wound should be done from top to center to outside.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?

a surgical incision with sutured approximated edges Explanation: Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention. Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention. Wounds that heal by secondary intention take longer to heal and form more scar tissue. Connective tissue healing and repair follow the same phases in healing. However, differences occur in the length of time required for each phase and in the extent of new tissue formed. Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed.

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury?

use pillows to maintain a side-lying position as needed Explanation: Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation of the skin. A foot board prevents foot drop but does not decrease the risk for pressure injury.