A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. When completing an incident about a pressure ulcer, the nurse should take which of the following actions?

Question the charge nurse about care deficits that might have contributed to the ulcer's development.

Document what the nurse believes was the cause of ulcer development

Include any relevant statements the client made about the ulcer

Document in the client's medical record that she completed an incident report

Answer and Explanation

The Correct Answer is C

Choice A rationale: The nurse should not include any opinions, judgments, or blame in the incident report, as this could be used as evidence in a legal case. Therefore, the nurse should not question the charge nurse about care deficits.
Choice B rationale: The nurse should not include any opinions, judgments, or blame in the incident report, as this could be used as evidence in a legal case. Therefore, the nurse should not document what the nurse believes was the cause of ulcer development.
Choice C rationale: This is important because it provides factual information about the client's condition and perception of the event, which could help in identifying the factors that contributed to the ulcer development and preventing further complications.
Choice D rationale: Documenting in the client's medical record that the nurse completed an incident report is not the primary purpose of the incident report itself. Incident reports are internal documents used by the healthcare facility to track and investigate events. The documentation in the client's medical record should focus on the client's clinical condition, care provided, and response to treatment.

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Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale: Hyperlipidemia, particularly elevated cholesterol levels, can be associated with impaired wound healing. High cholesterol levels can contribute to atherosclerosis, leading to reduced blood flow to the wound site. Adequate blood supply is crucial for delivering oxygen and nutrients essential for the healing process.
Choice B rationale: Diabetes mellitus is a well-known risk factor for delayed wound healing. High blood sugar levels can impair the function of white blood cells, reduce collagen formation, and impair the overall healing process. Furthermore, individuals with diabetes are more prone to infections and may experience slower wound closure.
Choice C rationale: Medication history alone does not provide specific information about factors that directly affect wound healing. However, certain medications, such as corticosteroids or immunosuppressive drugs, may impact the healing process.
Choice D rationale: High cholesterol levels can contribute to atherosclerosis, leading to reduced blood flow to the wound site. Adequate blood supply is crucial for delivering oxygen and nutrients essential for the healing process.
Choice E rationale: Prealbumin is a marker of protein status and nutritional adequacy. Low prealbumin levels can indicate malnutrition, which is a risk factor for delayed wound healing. Adequate protein intake is crucial for collagen synthesis and overall tissue repair.

A. Swab the wound bed with a sterile cotton-tipped swab B. Cleanse the area around the wound with sterile saline. C. Don sterile gloves D. Place the collection tube in a specimen bag.

Correct Answer is C

Explanation

- A: Swabbing the wound bed is an essential step in obtaining a wound culture, but it is not the first action that should be taken. This step is performed after the wound has been cleansed to ensure that the sample is not contaminated with debris or bacteria from the surrounding skin.
- B: Cleansing the area around the wound with sterile saline is the correct first step. This action helps to remove any contaminants or debris from the wound surface, ensuring that the culture obtained is from the wound itself and not from the surrounding skin, which could lead to inaccurate results.
- C: Donning sterile gloves is a crucial step to maintain sterility during the procedure. However, it is not the first action because the nurse must first cleanse the wound area to prevent contamination of the culture specimen.
- D: Placing the collection tube in a specimen bag is done after obtaining the wound culture to transport the specimen to the laboratory. This is one of the final steps in the process, not the first.

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A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. When completing an incident about a pressure ulcer, the nurse should take which of the following actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is scheduled for surgery. Exhibits The nurses review the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

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Correct Answer is C

Explanation

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