A patient presents with a skin abrasion on the forearm. Which of the following interventions is most important to prevent infection?

A. Ineffective airway clearance: This diagnosis focuses on obstruction of the airway by secretions or mechanical blockage. While relevant to some respiratory conditions, it does not directly address gas exchange impairment or the client’s anxiety.
B. Risk for infection: This diagnosis addresses potential for infection rather than current acute symptoms. It is preventive in nature and does not target immediate respiratory compromise or emotional distress.
C. Anxiety related to hospitalization: This diagnosis addresses only the psychological component. While the patient is anxious, this alone does not encompass the physiological issue of impaired oxygenation.
D. Impaired gas exchange related to anxiety and respiratory distress: This diagnosis integrates both physiologic and psychological factors affecting oxygenation. Anxiety can exacerbate respiratory distress, and this NANDA diagnosis allows for interventions targeting both improved oxygenation and anxiety reduction.

A. Perform passive range-of-motion exercises daily: Passive ROM helps maintain joint mobility and circulation, but it does not directly relieve pressure on bony prominences. While beneficial, it is not the most immediate intervention to prevent pressure injuries.

B. Encourage fluid intake to maintain hydration: Adequate hydration supports skin turgor and overall tissue health, reducing susceptibility to breakdown. However, hydration alone cannot relieve sustained pressure, so it is not the highest-priority action.

C. Reposition the patient every 2 hours: Frequent repositioning redistributes pressure over bony areas, preventing ischemia and tissue necrosis. For patients with limited mobility, this is the primary and most effective intervention to reduce the risk of pressure injuries.

D. Apply moisturizing lotion to dry skin: Moisturizing helps prevent skin dryness and minor abrasions, supporting skin integrity. It does not alleviate pressure on vulnerable areas and is therefore a secondary preventive measure rather than the priority intervention.