Question

question: 13 of 23
time remaining: 08:14:05
pause remaining: 00:05:00
a nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. which of the following nursing actions are appropriate? (select all that apply.)
(select all that apply.)
□ minimize skin exposure to moisture.
□ massage over erythematous bony prominences.
□ keep the client’s skin dry with powder.
☑ implement turning schedule every 4 hr.
□ use pillows to keep heels off the bed surface.

Explanation:

• Minimizing moisture reduces skin maceration, a risk factor for breakdown.
• Elevating heels with pillows relieves pressure on bony prominences, preventing ischemia.
• Massaging erythematous areas damages fragile skin; powder can cause irritation; turning every 4 hours is insufficient (should be q2h). Thus these are inappropriate.

Answer:

Minimize skin exposure to moisture., Use pillows to keep heels off the bed surface.