A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?

Choice A reason: Padding hard surfaces is a nursing intervention that decreases the risk of pressure injuries, because it reduces the pressure, shear, and friction on the skin and underlying tissues. Hard surfaces, such as bed rails, wheelchair arms, or footrests, can cause compression or irritation of the skin, especially over the bony prominences. Padding hard surfaces with foam, gel, or air cushions can provide protection and comfort for the client.

Choice B reason: Keeping head of bed (HOB) at or less than 30 degrees is a nursing intervention that decreases the risk of pressure injuries, because it prevents the sliding or shifting of the client in bed. Sliding or shifting can cause shear and friction on the skin, especially over the sacrum, coccyx, or heels. Keeping head of bed (HOB) at or less than 30 degrees can maintain the alignment and stability of the client in bed.

Choice C reason: Keeping head of bed (HOB) elevated to 75 degrees is not a nursing intervention that decreases the risk of pressure injuries, but rather one that increases the risk of pressure injuries. Elevating the head of bed (HOB) to 75 degrees can cause the client to slide or shift in bed, which can increase the shear and friction on the skin, as explained above. Elevating the head of bed (HOB) to 75 degrees can also increase the pressure on the sacrum, coccyx, or heels, which can impair the blood flow and oxygen delivery to the skin and tissues.

Choice D reason: Having client sit in wheelchair as much as possible is not a nursing intervention that decreases the risk of pressure injuries, but rather one that increases the risk of pressure injuries. Sitting in wheelchair as much as possible can cause prolonged pressure, shear, and friction on the skin and underlying tissues, especially over the ischial tuberosities, sacrum, coccyx, or heels. Sitting in wheelchair as much as possible can also reduce the mobility and activity of the client, which can affect the blood circulation and muscle tone.

Choice E reason: Placing pillows between bony surfaces is a nursing intervention that decreases the risk of pressure injuries, because it relieves the pressure, shear, and friction on the skin and underlying tissues. Bony surfaces, such as the ankles, knees, hips, or elbows, can cause compression or irritation of the skin, especially when they are in contact with each other or with the bed. Placing pillows between bony surfaces can provide cushioning and separation for the skin and tissues.

Choice A reason: This is an incorrect statement because it is not based on any assessment or diagnosis. Osteoporosis is a condition that affects the bones, not the joints. It also does not cause fatigue. The nurse should not make assumptions or give advice without proper evaluation.

Choice B reason: This is an incorrect statement because it is dismissive and insensitive. Arthritis is a general term that covers many types of joint inflammation and pain. It is not a simple condition that can be treated with just ibuprofen. The nurse should not minimize the patient's concerns or prescribe medication without a doctor's order.

Choice C reason: This is the correct statement because it shows empathy and interest in the patient's situation. It also helps the nurse gather more information about the onset, duration, frequency, and severity of the pain. This can help the nurse identify possible causes and plan appropriate interventions.

Choice D reason: This is an incorrect statement because it is rude and judgmental. Weight loss may or may not help with joint pain, depending on the underlying cause. The nurse should not blame the patient or make them feel guilty. The nurse should focus on the patient's current symptoms and needs, not their appearance or lifestyle.