A nurse is reinforcing teaching with a client about using a cane for ambulation. Which of the following statements should the nurse make?

A. Changing the patient's position every 30 minutes can help prevent pressure sores but this is such a short interval. The recommended interval is at least every 2 hours.
B. Every 180 minutes (or every 3 hours) is too long of an interval between position changes for a patient at risk for skin impairment. Prolonged pressure on bony
prominences increases the risk of pressure ulcer development.

C. Every 60 minutes (or every hour) is more frequent than every 180 minutes but may

still not be sufficient for preventing pressure ulcers in an unconscious patient with limited mobility.
D. For an unconscious patient at risk for skin impairment, it is recommended to reposition the patient at least every two hours to prevent pressure ulcers and skin breakdown. This frequency is a balance between providing adequate skin protection and minimizing the risk of injury to the patient or strain to the healthcare provider.

A. The list of medications is typically included in the Background component of the ISBARR communication tool, as it provides important information about the client's ongoing treatment and medications.

B. Treatment plans and interventions are generally discussed in the Assessment and Recommendation components of the ISBARR communication tool, as they involve the nurse's assessment of the client's condition and the actions recommended for continued care.
C. The Situation component of the ISBARR communication tool focuses on providing a concise summary of the client's current medical condition or status, including relevant changes since the last report or significant events that occurred during the shift.
D. Vital signs may be included as part of the Background or Assessment components of the ISBARR communication tool, depending on their relevance to the client's current condition and any changes observed during the shift.