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

question 26

Multiple Choice

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?

• A)Reactive hyperemia
• B)Stage I pressure ulcer
• C)Stage II pressure ulcer
• D)Stage III pressure ulcer