A Patient with a Nursing Diagnosis of Skin Integrity, Risk

A patient with a nursing diagnosis of Skin integrity, risk for impaired, is noted to have reddened areas on his right shoulder and hip when he is repositioned on a 2-hour turning schedule. The nurse should:

A) massage the areas vigorously to restore circulation to the pressured areas.
B) document that the patient has a stage I pressure ulcer of the right shoulder and hip.
C) not position the patient on the right side for at least 8 hours.
D) reassess the area after 30 to 45 minutes for reactive hyperemia.