In this NCLEX-RN question, explore the immediate nursing action required for a newly admitted client with a Stage I pressure injury on the sacrum.
The nurse in the emergency department notes a stage I pressure injury on the sacrum of a newly admitted client. Which action should the nurse take first?
A. Reposition the client to their side
B. Apply a topical emollient to the area
C. Document the findings in the electronic health record (EHR)
D. Notify the health care provider
Scroll down for the correct answer!
The correct answer to today’s NCLEX-RN® Question is…
A. Reposition the client to their side
Rationale: Repositioning the client should be done first to immediately relieve pressure from the injury and prevent further damage to the tissue.
Major Takeaway
It is the nurse’s responsibility to correctly assess, interpret, report, and document assessment findings. If an assessment reveals something that is potentially abnormal or emergent, such as a pressure injury, the nurse should reposition this patient right away to relieve pressure and prevent further damage to the tissue. Then, the nurse should report this to the health care provider while continuing to monitor the client’s progress or changes from baseline.
Incorrect Answer Explanations
B. Apply a topical emollient to the area
Rationale: The nurse should not apply any creams or ointments to the wound without first having the wound assessed by the health care provider. Application of inappropriate treatments could potentially cause further tissue injury.
C. Document the findings in the electronic health record (EHR)
Rationale: Documenting the findings related to the pressure injury is an important step in the overall care of this client. However, there is another action that should occur first.
D. Notify the healthcare provider
Rationale: Notifying the health care provider is an important step in the care of this client. However, there is another important step that should occur first.
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