88.What action should the nurse implement to prevent the formation
of a sacral ulcer for a client who is immobile?
A. Maintain in a lateral position using protective wrist and vest devices.
B. Position prone with a small pillow below the diaphragm.
C. Raise the head and knee gatch when lying in a supine position.
D. Transfer into a wheelchair close to the nurse's station for
observation.
The prone position (B) using a small pillow below the diaphragm
maintains alignment and provides the best pressure relief over the
sacral bony prominence. Using protective (restraining) devices (A) is
not indicated. Raising the head and bed gatch (C) may reduce
shearing forces due to sliding down in bed, but it interferes with
venous return from the legs and places pressure on the sacrum,
predisposing to ulcer formation. Sitting in a wheelchair (D) places the
of a sacral ulcer for a client who is immobile?
A. Maintain in a lateral position using protective wrist and vest devices.
B. Position prone with a small pillow below the diaphragm.
C. Raise the head and knee gatch when lying in a supine position.
D. Transfer into a wheelchair close to the nurse's station for
observation.
The prone position (B) using a small pillow below the diaphragm
maintains alignment and provides the best pressure relief over the
sacral bony prominence. Using protective (restraining) devices (A) is
not indicated. Raising the head and bed gatch (C) may reduce
shearing forces due to sliding down in bed, but it interferes with
venous return from the legs and places pressure on the sacrum,
predisposing to ulcer formation. Sitting in a wheelchair (D) places the
