A nurse assesses an area of pale white skin over a patient's coccyx. After turning the patient on her side, the skin becomes red and feels warm. What should the nurse do about these assessments?
A) Immediately report to the physician that the patient has a pressure ulcer.
B) Recognize that this is ischemia, followed by reactive hyperemia.
C) Document the presence of a pressure ulcer and develop a care plan.
D) Implement nursing interventions for Altered Skin Integrity.
Question 2
A nurse flushes an intravenous lock before and after administering a medication. What is the rationale for this step?
A) to keep the inside of the needle or catheter sterile
B) to facilitate patient comfort and decrease anxiety
C) to clear medication and prevent clot formation
D) to dilute the infusion and maintain homeostasis
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Palpating skin temperature