A nurse is caring for a client who is immobile. The nurse repositions the client from a supine to side-lying position and notices an area of redness and warmth over the greater trochanter. Which action by the nurse is appropriate?

When a nurse identifies an area of redness and warmth over a bony prominence such as the greater trochanter following repositioning, the first step is to reassess the area after the patient has been maintained off the area to determine whether the redness is blanchable or non-blanchable. Blanchable redness (reactive hyperemia) is a normal vascular response to pressure and typically resolves within 30 minutes once pressure is relieved. Non-blanchable redness, however, indicates a Stage 1 pressure injury, where there is persistent tissue damage despite removal of the pressure source. Repositioning the client and then reassessing allows the nurse to differentiate between these two findings before documenting a formal staging diagnosis. Massaging over a bony prominence is contraindicated and is explicitly against evidence-based guidelines; massage can cause further tissue damage and micro-tears to already compromised skin. Applying a cold compress is also inappropriate because cold causes vasoconstriction, which reduces blood flow to already ischemic tissue and worsens injury. Documenting a Stage 1 pressure injury without first reassessing to confirm non-blanchability would be premature and potentially inaccurate. The appropriate nursing action is to reassess after repositioning to determine the nature of the redness before any formal documentation or intervention is made, making this the most clinically sound choice.