Question

a nurse is caring for a client who is at risk for developing pressure injury. which of the following interventions should the nurse use to help maintain the integrity of the clients skin? select all that apply. a keep the head of the bed elevated 30°. b massage the clients bony prominences frequently. c apply cornstarch liberally to the skin after bathing. d have the client sit on a gel cushion when in a chair. e reposition the client every 3 hr while in bed.

Explanation:

• Option A: Keeping the head of the bed elevated \(30^{\circ}\) helps reduce shear forces on the skin, which is beneficial for skin integrity in clients at risk of pressure injury.
• Option B: Massaging bony prominences frequently can cause micro - trauma to the skin and underlying tissues, so this is not an appropriate intervention.
• Option C: Applying cornstarch liberally can lead to caking and maceration of the skin when it gets moist, so it is not a good practice.
• Option D: Having the client sit on a gel cushion when in a chair helps distribute pressure, reducing the risk of pressure injury and maintaining skin integrity.
• Option E: Repositioning the client every \(2\) hours (not \(3\) hours) is the standard practice. Repositioning every \(3\) hours may not be frequent enough to prevent pressure injury.

Answer:

A. Keep the head of the bed elevated \(30^{\circ}\), D. Have the client sit on a gel cushion when in a chair.