After completing a scheduled every-2-hour turn by turning the client to the left side,the nurse notices a reddened area over the coccyx.The area blanches when the nurse compresses it with thumb pressure.One hour later,the nurse reassesses the area and finds the redness has disappeared.How should the nurse document this area?

Question

Quizplus · Accepted Answer

Reactive hyperemia is a transient redness that occurs when pressure is relieved. The fact that the redness disappeared within an hour suggests that it was reactive hyperemia rather than a pressure ulcer. Choice B, C, and D are all incorrect as they indicate the presence of a pressure ulcer, which was not confirmed in this case.

After Completing a Scheduled Every-2-Hour Turn by Turning the Client