The nurse notes a reddened area on the right heel that does not turn lighter in color when pressed with a finger.
Which term will the nurse use to describe this area?
Secondary erythema.
Nonblanchable erythema.
Blanchable hyperemia.
Reactive hyperemia.
The Correct Answer is B
Choice A rationale:
Secondary erythema refers to redness that develops after the initial injury or insult. It's not the most accurate term to describe an area that doesn't blanch, as blanching specifically assesses for the presence of blood in the tissue. Secondary erythema can be blanchable or nonblanchable, depending on the underlying cause.
Choice C rationale:
Blanchable hyperemia is a reddening of the skin that blanches (turns lighter) when pressed. This indicates that blood is still flowing to the area and that the tissue is not damaged. It's not the correct term for an area that doesn't blanch.
Choice D rationale:
Reactive hyperemia is a temporary increase in blood flow to an area that has been deprived of blood flow. It's often seen after pressure is relieved from a body part. While reactive hyperemia can cause redness, this redness typically blanches when pressed.
Choice B rationale:
Nonblanchable erythema is the most accurate term to describe an area of redness that does not turn lighter in color when pressed with a finger. This indicates that blood is not flowing to the area and that the tissue is likely damaged. Nonblanchable erythema is a significant finding because it can be a sign of a pressure injury (also known as a bedsore or pressure ulcer).
Key points about nonblanchable erythema:
It's a sign of impaired blood flow to the tissue. It's a potential indicator of a pressure injury.
It requires prompt assessment and intervention to prevent further tissue damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Step 1: Convert the prescribed dose to milligrams. 400 mcg = 0.4 mg (since 1 mg = 1000 mcg)
Step 2: Compare the prescribed dose to the pill strength. The prescribed dose is 0.4 mg.
The pill strength is 0.4 mg.
Step 3: Determine the number of pills needed.
Since the prescribed dose and pill strength are equal, only one pill is needed to administer the correct dose.
Rationale for Choice A:
Correct: One pill of 0.4 mg will provide the exact dose of 400 mcg that has been prescribed.
Direct match: The pill strength matches the prescribed dose, eliminating the need for any calculations or adjustments.
Therapeutic equivalence: Administering one pill ensures that the patient receives the intended amount of medication to achieve the desired therapeutic effect.
Adherence to prescription: Conforms to the healthcare provider's instructions, promoting accurate and safe medication administration.
Correct Answer is D
Explanation
Choice A rationale:
Aspirating prior to injecting enoxaparin is not recommended.
Aspiration was once a common practice to check if a needle had entered a blood vessel.
However, research has shown that aspiration is not necessary for subcutaneous injections and may even be harmful. It can cause pain, bruising, and hematoma formation.
Additionally, aspirating can increase the risk of needlestick injuries.
For these reasons, aspiration is no longer recommended for subcutaneous injections of enoxaparin or other anticoagulants.
Choice B rationale:
Massaging the injection site after administering enoxaparin is not recommended. Massaging can increase the risk of bruising and hematoma formation.
It can also cause the medication to be absorbed too quickly, which can increase the risk of bleeding.
The best practice is to apply gentle pressure to the injection site with a dry gauze pad for a few seconds after the injection. This will help to prevent bleeding and bruising.
Choice C rationale:
The size of the syringe and needle used to administer enoxaparin is not specified in the question. However, a 1-mL syringe with a 32-gauge needle is a common choice for subcutaneous injections.
This size syringe is small enough to be easy to handle, and the 32-gauge needle is thin enough to minimize discomfort.
Choice D rationale:
The abdomen is the preferred site for subcutaneous injections of enoxaparin.
The abdomen has a large surface area of soft tissue, which makes it easy to inject the medication.
The abdomen is also relatively free of blood vessels and nerves, which reduces the risk of bruising, bleeding, and pain. Other potential injection sites for enoxaparin include the upper arms, thighs, and buttocks.
However, the abdomen is generally the preferred site.
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