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 C
Explanation
Choice A rationale:
While providing meticulous oral care and allowing ice chips for dry mouth can promote comfort, it does not address the primary concern of absent bowel sounds.
Ice chips could potentially stimulate bowel activity, but this is not a reliable or recommended method for managing absent bowel sounds in the immediate postoperative period.
It's essential to prioritize actions that assess and address the potential causes of absent bowel sounds, as they can indicate serious complications.
Choice B rationale:
Notifying the surgeon immediately and preparing for emergency surgery is not the appropriate first course of action in this situation.
Emergency surgery would be considered only if there were clear signs of a life-threatening complication, such as bowel perforation or peritonitis.
These complications would typically present with additional symptoms such as severe abdominal pain, fever, and hemodynamic instability.
Absent bowel sounds alone, without other concerning signs, do not warrant immediate surgical intervention.
Choice D rationale:
Allowing the patient to have clear liquids as tolerated is not appropriate when bowel sounds are absent. Introducing oral intake before bowel function has returned can increase the risk of nausea, vomiting, and aspiration.
It's crucial to wait for the return of bowel sounds before initiating oral intake to ensure proper digestion and minimize complications.
Choice C rationale:
Keeping the patient NPO (nothing by mouth) is the most appropriate action when bowel sounds are absent after major abdominal surgery.
This allows the bowel to rest and recover from the surgical manipulation.
It also prevents potential complications such as aspiration and nausea/vomiting that could arise from premature oral intake.
Documenting the absence of bowel sounds in the patient's medical record is essential for communication among healthcare providers and for monitoring the patient's progress.
This documentation provides a clear record of the patient's clinical status and facilitates appropriate decision-making regarding further interventions.
Correct Answer is B
Explanation
Choice A rationale:
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.