When changing the soiled linen on the bed of a client who is comatose,

When changing the soiled linen on the bed of a client who is comatose, the nurse notices a red-dened, blanchable area approximately 2 cm in diameter on her left buttock. The nurse’s initial skin breakdown intervention is to:

1. Position the client on her right side
2. Finish providing fresh, dry linen to the client’s bed
3. Include a 2-hour turning schedule in the client’s care plan
4. Measure the area in order to describe it in the nurses’ notes

ANSWER

ANS: 1
Pressure is the major cause in pressure ulcer formation, and changing the client’s position to minimize the time spent in a particular position will be the best intervention to relieve the pres-sure. The remaining options are appropriate, but none has priority over proper positioning of the client.