Which assessment finding indicates that the patient is at high risk for development of pulmonary embolism?

Choice A rationale:

Employee Assistance Programs (EAPs): These programs focus on providing confidential counseling and support services to employees for personal and work-related issues, such as mental health, substance abuse, stress management, and family concerns. They do not play a role in determining nursing training requirements for intravenous line initiation.

Choice C rationale:

The MedWatch program: This is a voluntary reporting system for healthcare professionals and consumers to report adverse events and medication errors to the FDA. It's crucial for monitoring drug safety but does not establish training standards for nurses.

Choice D rationale:

The US Food and Drug Administration (FDA): This federal agency regulates food, drugs, medical devices, and cosmetics to ensure their safety and efficacy. While it sets standards for drug approval and labeling, it does not directly determine specific nursing training requirements.

Choice B rationale:

State Nurse Practice Acts: These laws, enacted by each state's legislature, define the scope of nursing practice, including the skills and tasks that nurses are legally authorized to perform. Intravenous line initiation is a skill that falls within the scope of nursing practice, and the specific training requirements for this skill are typically outlined in each state's Nurse Practice Act.

Key points:

State Nurse Practice Acts are the primary legal authority governing nursing practice within each state, including the necessary training for nurses to perform specific skills.

EAPs, MedWatch, and the FDA play important roles in healthcare but do not determine nursing training requirements

Nurses must be aware of the Nurse Practice Act in their state to ensure they are practicing within the legal scope of their profession and have received the required training for the skills they perform.

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.