Question

a nurse is developing a plan for repositioning a client who has physical limitations due to recent back surgery. which action should the nurse take?

adhere to a strict every 2-hour turning schedule.
tailor the frequency of turning to the clients needs and responses.
allow the client to determine when repositioning is needed.
maintain the client in proper alignment in the supine position.

Explanation:

Analyze the clinical scenario

The client has physical limitations following recent back surgery. When planning care, interventions must promote safety, prevent pressure injuries, and accommodate the client's specific surgical recovery needs.

Evaluate the options

Using the Individualized Care Planning knowledge point:

• Adhere to a strict every 2-hour turning schedule: While a 2-hour schedule is a common baseline, rigid schedules do not account for individual risk factors, skin condition, or comfort.
• Tailor the frequency of turning to the client's needs and responses: This represents the gold standard of individualized care. Turning frequency should be adjusted based on skin assessments, tissue tolerance, and patient comfort.
• Allow the client to determine when repositioning is needed: Clients with physical limitations or post-surgical pain may not self-reposition adequately, putting them at risk for pressure injuries.
• Maintain the client in proper alignment in the supine position: Keeping a patient solely in one position (supine) increases the risk of pressure injuries on bony prominences like the sacrum.

Using the Patient Positioning knowledge point:

• Repositioning must be dynamic and tailored to prevent localized tissue ischemia while maintaining spinal alignment.

Select the best action

Tailoring the turning frequency to the client's specific needs and responses ensures safe, individualized, and evidence-based care.

Answer:

• Adhere to a strict every 2-hour turning schedule.
• Tailor the frequency of turning to the client's needs and responses. (Correct answer)
• Allow the client to determine when repositioning is needed.
• Maintain the client in proper alignment in the supine position.