Pressure ulcers are defined as an injury to the skin and/or underlying tissue resulting from pressure or in combination with shear, usually over a bony prominence. As a nurse, what do you know you must do to prevent pressure ulcers? (Select all that apply.)

Choice A reason: Teaching the client alternative comfort measures is not the best recommendation for the nurse to implement, as it may imply that the client's pain is not taken seriously or that the nurse is reluctant to provide pain relief. The nurse would teach the client alternative comfort measures, such as relaxation techniques, distraction, or massage, as a supplement to the pain medication, not as a substitute.

Choice B reason: Telling the client that it is too soon for pain medication is not a good recommendation for the nurse to implement, as it may make the client feel dismissed, ignored, or judged. The nurse would follow the prescribed pain medication schedule, but also consider the client's individual needs and preferences, and adjust the dosage or frequency as needed, with the doctor's approval.

Choice C reason: Administering the pain medication as requested by the client is not a safe recommendation for the nurse to implement, as it may cause overdose, addiction, or adverse effects. The nurse would administer the pain medication as prescribed by the doctor, and monitor the client's response, side effects, and vital signs.

Choice D reason: Validating the pain with other assessment data is the best recommendation for the nurse to implement, as it shows respect, empathy, and professionalism. The nurse would acknowledge the client's pain, ask about the location, intensity, quality, and duration of the pain, and use a pain scale or a pain assessment tool to measure the pain. The nurse would also check for any physical or behavioral signs of pain, such as grimacing, guarding, or restlessness. The nurse would document the pain assessment and report any changes or concerns to the doctor.

Choice A reason: Raises all four side rails is not the best intervention, as it may not prevent the client from falling and may increase the risk of injury and entrapment. Raising all four side rails may also be considered a form of restraint, which should be avoided unless absolutely necessary.

Choice B reason: Orders a two-person assist with a transfer is not the best intervention, as it may not be appropriate for the client's level of mobility and may reduce the client's independence and self-esteem. The nurse should assess the client's ability to transfer and use the appropriate assistive device and number of staff to ensure safety and comfort.

Choice C reason: Gives the client a dry erase board is the best intervention, as it can facilitate the client's communication and expression of needs and preferences. The client may have difficulty speaking or writing due to the stroke, which can affect the language and motor areas of the brain. A dry erase board can allow the client to use simple words, symbols, or drawings to convey their messages.

Choice D reason: May need to incorporate repetition is not the best intervention, as it is not specific and may not be effective for the client's learning and retention. The nurse should use individualized and evidence-based strategies to teach the client and their family about the stroke, its effects, and the rehabilitation plan. Repetition may be one of the strategies, but not the only one.

Choice E reason: None of the above is not the correct answer, as there is one choice that is the best intervention for the nurse to implement when caring for this client.