When Changing the Soiled Linen on the Bed of a Client

question 20

Multiple Choice

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

• A) Position the client on her right side
• B) Finish providing fresh,dry linen to the client's bed
• C) Include a 2-hour turning schedule in the client's care plan
• D) Measure the area in order to describe it in the nurses' notes

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