A nurse is assisting with developing a plan of care for a client who is immobilized. Which of the following interventions should the nurse recommend to reduce the development of pressure ulcers?

A. Pale-colored toes are a sign of compromised circulation, which is a key manifestation of compartment syndrome. Decreased blood flow to the affected limb can cause pallor, which requires immediate intervention to prevent permanent damage.

B. Decreased skin turgor is incorrect. Skin turgor is an indicator of hydration status and is not directly related to compartment syndrome.

C. Pain relieved by analgesia is incorrect. One of the hallmark signs of compartment syndrome is severe pain that is not relieved by analgesia and worsens with passive movement.

D. Diminished capillary refill is correct. Delayed capillary refill (longer than 2 seconds) suggests poor perfusion, which can indicate increased pressure within the compartment.

E. Sensation of tingling is correct. Paresthesia (tingling or numbness) is an early sign of nerve compression due to swelling within the compartment. If untreated, this can progress to permanent nerve and muscle damage.

A. Measure the duration of the seizure. This is the correct action. Monitoring the duration of the seizure is important for assessing its severity and deciding when to intervene medically. A seizure lasting longer than 5 minutes requires immediate intervention.

B. Lower the side rails of the bed when the seizure begins. This is not recommended. The side rails should be raised to protect the client from injury. Lowering them could increase the risk of falling out of bed.

C. Insert an oral airway into the client's mouth. This is incorrect. Inserting an airway into the mouth during a seizure can be dangerous and may result in injury to the client or the nurse. The client’s airway should be kept clear, but inserting an object into the mouth is not recommended.

D. Restrain the client's arms and legs to prevent injury. This is incorrect. Restraining the client during a seizure can cause injury to both the client and the nurse. It is better to allow the seizure to proceed naturally while ensuring the client is protected from injury (e.g., by placing a soft pillow under their head or cushioning hard surfaces around them).