NCLEX · Basic Care and Comfort

An immobile client is at risk for pressure injury. How often should the nurse reposition a bedbound client to prevent skin breakdown?

Correct answer

At least every 2 hours — repositioning relieves pressure over bony prominences before tissue ischemia and breakdown occur; more frequent repositioning may be needed for high-risk clients

  1. A Every 8 hours
  2. B At least every 2 hours — repositioning relieves pressure over bony prominences before tissue ischemia and breakdown occur; more frequent repositioning may be needed for high-risk clients
  3. C Once per shift
  4. D Only when the client requests it

Why this is the answer

PRESSURE INJURY PREVENTION — REPOSITIONING: Reposition bedbound clients at least every 2 hours (chair-bound: every 1 hour or teach weight shifts every 15 minutes); WHY: Pressure over bony prominences (sacrum, heels, hips, elbows, occiput) compresses capillaries, causing tissue ischemia; unrelieved pressure for as little as 2 hours can begin tissue damage; PREVENTION BUNDLE: Repositioning schedule; pressure-redistributing surfaces (specialty mattress); keep skin clean and dry; manage moisture (incontinence); adequate nutrition and hydration (protein for tissue integrity); float heels off the bed; avoid friction and shear (lift, don't drag); use the Braden Scale to assess risk; PRESSURE INJURY STAGES: Stage 1 (non-blanchable erythema, intact skin) through Stage 4 (full thickness with exposed bone/muscle), plus unstageable and deep tissue injury; LPN role: reposition per schedule, assess skin every shift, document, report any skin changes (early Stage 1 is reversible with intervention).
Source: NCLEX-PN Physiological — Basic Care, Pressure Injury Repositioning