The nurse aide identifies a reddened area that does not blanch over the client’s sacrum. The nurse aide should
  1. Massage the area four times each day.
  2. Perform range-of-motion exercises with the client.
  3. Keep the area covered with a sterile dressing.
  4. Reposition the client regularly throughout the day.
Explanation
Answer: D - The nurse aide should reposition an immobile client every two hours while in bed and every hour in a chair in order to prevent pressure ulcers. Massaging the area will help increase blood flow, but the priority treatment to prevent further breakdown is repositioning. Performing range-of-motion exercises with the client will help to prevent complications of immobility, but frequent repositioning, pressure relief devices, and skin care can help prevent pressure ulcers. If a pressure ulcer forms, a dressing can be used to expedite healing by removing unwanted debris from the ulcer surface, protecting exposed viable tissues, and or providing a barrier between an open ulcer and the environment. Applying sterile dressings is more of a responsibility of the licensed nurse.
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