An area of erythema on the child's skin is being assessed by the nurse. The nurse presses down on the area, and the area becomes white. What term does the nurse document for this finding?

Choice A reason: Culturing the wound is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Culturing the wound is a procedure that involves collecting a sample of the wound drainage and sending it to the laboratory for analysis, which can help identify the type and source of infection. Culturing the wound is an important intervention, but it should be done after inspecting the wound and assessing the drainage, and with a medical order and a sterile technique.

Choice B reason: Applying topical ointment to the wound is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Applying topical ointment to the wound is a procedure that involves applying a medication or a dressing to the wound site, which can help prevent or treat infection, inflammation, or pain. Applying topical ointment to the wound is an important intervention, but it should be done after inspecting the wound and assessing the drainage, and with a medical order and a clean technique.

Choice C reason: Inspecting the wound and assessing the drainage is the nurse's priority assessment for this client, because it is the most urgent and relevant action. Inspecting the wound and assessing the drainage is a process that involves observing and measuring the wound site and the wound exudate, which can reveal the presence and severity of infection, injury, or healing. Inspecting the wound and assessing the drainage is an essential assessment, as it can guide the diagnosis, treatment, and evaluation of the client's condition.

Choice D reason: Calling the provider to initiate antibiotics is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Calling the provider to initiate antibiotics is a communication that involves reporting the client's situation and requesting a prescription for an antimicrobial agent, which can help fight or prevent infection. Calling the provider to initiate antibiotics is an important communication, but it should be done after inspecting the wound and assessing the drainage, and with the necessary data and documentation.

Choice A reason: Postponing daily bed bath is not appropriate for reducing the risk of a friction and shear injury. Bed bath is a hygiene measure that helps to keep the skin clean and dry and prevent infection. Friction and shear are caused by the rubbing and pulling of the skin against the bed surface, not by the bed bath itself.

Choice B reason: Elevating the client’s head of the bed to 45 degrees is not appropriate for reducing the risk of a friction and shear injury. In fact, this may increase the risk as the client may slide down the bed due to gravity and cause more friction and shear on the skin. The head of the bed should be kept at the lowest possible angle, preferably less than 30 degrees, unless contraindicated by the client’s condition.

Choice C reason: Caregiver independently slides the client up in bed is not appropriate for reducing the risk of a friction and shear injury. This may cause more damage to the skin as the caregiver may exert excessive force and drag the client’s skin along the bed surface. The caregiver should use a draw sheet or a slide board to lift and reposition the client with the help of another person.

Choice D reason: Use a mechanical lift to reposition the client every 2 hours is the most appropriate intervention for reducing the risk of a friction and shear injury. A mechanical lift is a device that helps to transfer and reposition the client safely and comfortably. It reduces the friction and shear on the skin by lifting the client off the bed surface and avoiding any sliding or dragging. It also prevents the caregiver from injuring themselves by lifting the client manually. The client should be repositioned every 2 hours to relieve the pressure on the skin and prevent pressure ulcers.