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.

Answer and Explanation

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.

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Correct Answer is ["A","B","C","F","G"]

Explanation

Rationale for each choice:

Choice A: Hypovolemia

Impaired perfusion: Hypovolemia, or a decrease in circulating blood volume, leads to reduced blood flow to the wound site. This means that less oxygen and nutrients are delivered to the tissues, which are essential for healing processes like cell growth and collagen synthesis.

Impaired oxygen delivery: Oxygen is crucial for white blood cells to fight infection and for fibroblasts to create new tissue. Hypovolemia can significantly hinder wound healing by reducing oxygen availability at the wound site.

Delayed inflammatory response: The inflammatory phase of wound healing relies on adequate blood flow to deliver immune cells and initiate tissue repair. Hypovolemia can delay this response, leading to prolonged inflammation and delayed healing.

Decreased fibroblast activity: Fibroblasts, the cells responsible for collagen production, require oxygen and nutrients to function effectively. Hypovolemia can impair fibroblast activity, leading to reduced collagen synthesis and delayed wound closure.

Choice B: Poorly controlled blood glucose levels

Impaired immune function: High blood glucose levels impair the function of white blood cells, making the body more susceptible to infections. Infections at the wound site can significantly delay healing.

Impaired collagen synthesis: Hyperglycemia can also impair collagen synthesis, which is essential for wound strength and closure.

Vascular damage: Chronically high blood glucose levels can damage blood vessels, leading to impaired blood flow and oxygen delivery to the wound site, further hindering healing.

Choice C: Protein deficiency

Impaired collagen synthesis: Protein is a crucial building block for collagen, the main structural protein in connective tissue. A lack of protein can lead to reduced collagen production, resulting in delayed wound healing and weaker scar tissue.

Impaired immune function: Protein is also essential for immune cell function. A deficiency can impair the body's ability to fight infections, increasing the risk of wound complications.

Choice D: Adequate hydration

Incorrect: Staying well-hydrated supports the body’s healing process by ensuring proper blood flow and nutrient transport, thus it does not impede wound healing.

Choice E: Routine ambulation

Incorrect: Early ambulation after surgery promotes healing by improving circulation and reducing the risk of complications like blood clots, making it beneficial rather than harmful.

Choice F: Steroid therapy

Immunosuppressive effects: Steroids suppress the immune system, making the body less able to fight infections and hindering the inflammatory phase of wound healing.

Decreased collagen synthesis: Steroids can also decrease collagen synthesis, leading to weaker wound tissue and delayed closure.

Choice G: Obesity

Impaired blood flow: Excess adipose tissue can compress blood vessels, reducing blood flow to the wound site and impairing oxygen and nutrient delivery.

Increased inflammation: Adipose tissue produces inflammatory cytokines, which can prolong the inflammatory phase of wound healing and delay tissue repair.

Higher risk of infection: The folds of skin in obese individuals can create moist environments that are more prone to bacterial growth and infection.

Choice H: Vitamin C supplementation

Incorrect: Vitamin C plays a key role in collagen formation and tissue repair, so it supports rather than hinders wound healing.

A. Mix the detemir and aspart in the same syringe, drawing up the aspart first. B. Mix the detemir and aspart in the same syringe, drawing up the detemir first. C. Draw up the aspart in one syringe and the detemir in another. D. Draw up the detemir in one syringe and the aspart in another.

Correct Answer is C

Explanation

Rationale for Choice A:

Mixing insulin detemir and insulin aspart in the same syringe is not recommended due to their differing physicochemical properties and potential for altered absorption and action profiles.

It's crucial to follow manufacturer guidelines, as mixing may lead to suboptimal glycemic control or unpredictable insulin activity.

Rationale for Choice B:

The order of mixing insulin detemir and insulin aspart, even if done incorrectly in the same syringe, would not significantly impact the overall contraindication of mixing them.

The primary concern remains the potential for altered pharmacodynamics and pharmacokinetics when these insulins are combined.

Rationale for Choice C:

Drawing up insulin aspart and insulin detemir in separate syringes is the correct procedure.

This approach ensures that each insulin maintains its intended action profile and absorption characteristics, leading to more predictable glycemic control.

It also aligns with best practices and guidelines for insulin administration.

Rationale for Choice D:

While drawing up insulin detemir first in a separate syringe is technically correct, it offers no specific advantage over drawing up insulin aspart first in a separate syringe.

The key principle is to avoid mixing the two insulins in the same syringe.

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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?

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Explanation

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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?

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?