Question

The nurse is prioritizing care to prevent pressure sores for a client who is immobilized. Which interventions are appropriate? (Select all that apply.)

A Use a rubber ring to decrease sacral pressure when up in the chair.
B. Place a small pillow between bony surfaces.
C. Keep the heels off the bed surfaces.
D. Use a lift sheet to assist with repositioning.
E. Reposition the client who is in a chair every 2 hours.
F. Elevate the head of the bed to 45 degrees.
G. Limit fluids and proteins in the diet.

Answer 1

To prevent pressure sores in an immobilized client, appropriate interventions include using a rubber ring, placing a small pillow between bony surfaces, keeping the heels off the bed surfaces, using a lift sheet, repositioning the client every 2 hours, and elevating the head of the bed.

Step-by-step explanation:

To prevent pressure sores for an immobilized client, the nurse can implement several appropriate interventions:

1. Use a rubber ring to decrease sacral pressure when the client is up in the chair.
2. Place a small pillow between bony surfaces to relieve pressure.
3. Keep the heels off the bed surfaces to minimize pressure.
4. Use a lift sheet to assist with repositioning to reduce prolonged pressure on specific areas.
5. Reposition the client who is in a chair every 2 hours to distribute pressure and relieve susceptible areas.
6. Elevate the head of the bed to 45 degrees to help prevent pressure on the sacrum.

Limiting fluids and proteins in the diet (option G) is not appropriate for preventing pressure sores. In fact, adequate hydration and nutrition are important to maintain skin health.