For an immobile, elderly male patient with a blood pressure of 138/60 mm Hg, what is an appropriate nursing action?

• A. Administer antihypertensive medication
• B. Increase fluid intake
• C. Turn the client every 2 hours
• D. Elevate the legs

Answer: (C)

Prolonged immobility increases the risk of pressure injuries because constant pressure over bony areas reduces capillary blood flow and leads to tissue damage. Turning the client every two hours relieves that pressure, redistributes it to different areas, and improves tissue perfusion, which helps prevent skin breakdown and ulcers. The blood pressure reading doesn’t by itself necessitate antihypertensive medication, and such therapy requires a provider’s orders and assessment. Increasing fluids or elevating the legs doesn’t address the primary risk to skin integrity in an immobile elderly patient, so repositioning remains the most appropriate preventive action.