The nurse is caring for a client who is on airborne precautions. What action should the nurse take when using personal protective equipment (PPE)?

Rationale for correct choices

• Non-blanchable erythema: Stage 1 pressure injuries are characterized by intact skin with non-blanchable redness over a bony prominence. The redness does not turn white when pressure is applied, indicating underlying tissue compromise. Early identification at this stage allows for interventions to prevent progression.

• Stage 1: A Stage 1 pressure injury involves superficial skin changes without partial or full-thickness tissue loss. The classification helps guide preventive measures, such as repositioning, pressure-relieving devices, and skin protection strategies.

Rationale for incorrect choices

• Partial-thickness loss of dermis: Partial-thickness loss of dermis corresponds to a Stage 2 pressure injury, not Stage 1. This stage presents as a shallow open ulcer or blister, indicating more advanced skin breakdown than non-blanchable erythema.

• Full-thickness tissue loss: Full-thickness tissue loss is seen in Stage 3 or Stage 4 pressure injuries. These involve deeper tissue layers, potentially including fat, muscle, or bone, and are more severe than Stage 1 injuries.

• Stage 4: Stage 4 pressure injuries involve extensive tissue damage to muscle, bone, or supporting structures. Non-blanchable erythema alone does not indicate this severity.

• Unstageable: Unstageable pressure injuries occur when the base of the wound is obscured by slough or eschar, making accurate staging impossible. Non-blanchable erythema is visible and can be staged as Stage 1.

A. A client with an abnormal gait who takes an anticonvulsant medication: This client is at increased fall risk due to gait instability and potential medication side effects. However, if the client can request assistance and is cognitively intact, the immediate risk is lower than for clients with impaired judgment.

B. A client with lower extremity weakness and dementia: Dementia impairs judgment, awareness of limitations, and the ability to request help, while lower extremity weakness compromises mobility. This combination places the client at highest immediate risk for unassisted falls, making activation of the bed alarm a priority.

C. A client with visual impairment who calls for assistance when needed: While visual deficits increase fall risk, the client’s ability to recognize limitations and seek help mitigates immediate danger. The fall risk is present but less urgent than for a cognitively impaired client who may attempt to get out of bed unassisted.

D. A client with hypotension who uses a walker to ambulate: Hypotension may cause dizziness, increasing fall risk during ambulation. However, if the client waits for assistance and uses mobility aids appropriately, the risk of unassisted falls is lower than in a client with dementia and mobility weakness.