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The sacral area has remained red for two hours and does not blanch when tested.
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The nurse applies light pressure with the fingertips to assess for blanching.
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In accession to measuring the length of the time the inflammation lasts, which appraisal measure should the nurse perform?
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Which areas are most important for the nurse to observe for additional pressure ulcers
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What to tell charge nurse about skin integrity?
Assure the charge nurse that written instructions in the client's room are effective and do not violate any client rights. A written, individualized schedule is the most effective method to ensure consistent positioning and may be placed in the client's room without compromising client confidentiality.
How to observe for wound approximation with Hesi?
B) Observe for wound approximation. D) Gently lift a fold of skin. A) Apply light pressure to the area with the fingertips. Rationale: The RN applies light pressure with the fingertips to asses for blanching. This is a normal response in light-skinned clients, which indicates there is no tissue perfusion impairment.
What do you need to know about skin integrity?
A) Provide verbal instructions about positioning to the UAP and document the instructions in the nurse's notes. C) Advise the charge nurse that client confidentiality is secondary to the continuity of care. D) Assure the charge nurse that written instructions in the client's room are effective and do not violate any client rights.
How to measure skin integrity with a Hesi flashcard?
A) Apply light pressure to the area with the fingertips. B) Measure the diameter of the redness. B) Observe for wound approximation. D) Gently lift a fold of skin. A) Apply light pressure to the area with the fingertips. Rationale: The RN applies light pressure with the fingertips to asses for blanching.
Last Update: Oct 2021
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