hard · NCLEX-RN basic-care
During a skin assessment, the nurse identifies a 3 cm area of non-blanchable erythema on a client's sacrum. The skin is intact and feels warmer than the surrounding tissue.
Which action is the priority to include in the plan of care?
- Apply a transparent film dressing to protect the area from moisture, for this client.
- Cleanse the area with an antiseptic solution and leave it open to the air.
- Massage the reddened area frequently to improve local blood flow.
- Reposition the client every 2 hours and use a pressure-redistribution surface.
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