Reduction of Risk Potential Practice Question
Question
The nurse is caring for a client after a procedure and is focused on pressure injury prevention scenario 3. Which nursing action is most appropriate?
Answer choices
- A. Reposition, protect skin, manage moisture, and optimize nutrition.
- B. Delay assessment until the next scheduled round if the client is not calling for help.
- C. Delegate the clinical assessment and nursing judgment to assistive personnel.
- D. Document the concern without notifying the appropriate provider or care team member when escalation is needed.
Correct Answer
A. Reposition, protect skin, manage moisture, and optimize nutrition.
Explanation
The priority action for pressure injury prevention is to reposition, protect skin, manage moisture, and optimize nutrition. NCLEX-style prioritization favors safety, assessment, appropriate delegation, timely escalation, and client-centered teaching.
Question details
- Difficulty: easy
- Domain: Reduction of Risk Potential
- Objective: pressure injury prevention