Basic Care and Comfort NCLEX PN Questions Nursing Practice Question
The hospitalized client with limited mobility is at risk for skin breakdown. Which interventions should the nurse include in the plan of care to maintain the client's skin integrity? Select all that apply.
Correct Answer: C,D,E,F
Rationale: Maintaining skin integrity in clients with limited mobility involves proactive measures. Applying a moisturizing lotion (C) helps hydrate the skin, preventing dryness and potential breakdown. Instructing the client to change positions every 2 hours (D) is crucial to alleviate pressure on bony prominences, reducing the risk of pressure ulcers. Using an overhead trapeze (E) promotes mobility, allowing the client to adjust their position more easily.
In contrast, massaging vigorously over bony prominences (A) can damage fragile skin and increase the risk of breakdown. Wearing sterile gloves when inspecting skin (B) is unnecessary unless there’s a risk of infection; clean gloves suffice. Applying a barrier cream (F) is essential for incontinent clients to protect the skin from moisture and irritation.