A client has the nursing diagnosis Risk for Impaired Skin Integrity re

A client has the nursing diagnosis Risk for Impaired Skin Integrity related to immobility. Which nursing intervention should be identified for this client’s problem?

1. Encourage the client to eat at least 40% of meals.
2. Keep linens dry and wrinkle-free.
3. Restrict fluid intake.
4. Turn client every 3 hours.

ANSWER

Correct Answer: 2
Rationale 1: For nutritional support to promote healthy tissue, clients should consume more than 40% of their meals.
Rationale 2: Keeping linens dry and wrinkle-free will prevent pressure areas.
Rationale 3: Fluids should not be restricted unless some other physical condition dictates. The skin should be kept hydrated.
Rationale 4: To relieve pressure, the client should be turned every 2 hours, not every 3.