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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: white-or flesh-colored papillary growths in the genital region is a common finding in human papillomavirus (HPV) infection, not HSV 2 infection.
Choice B rationale: a patient with HSV 2 usually develop influenza-like symptoms such as headache, muscle aches, fever, and generalized body malaise. However, the above symptoms usually subside within a few days to weeks.
Choice C rationale: anuria refers to the absence of urine output indicating renal failure which is not associated with HSV 2 infection.
Choice D rationale: green penile discharge is associated with gonorrhea infection rather than HSV 2 infection.
Correct Answer is A
Explanation
Choice A rationale: Transparent dressings are commonly used for stage I pressure ulcers as they provide a protective barrier against external contaminants while allowing for visualization of the wound. This type of dressing helps maintain a moist environment to facilitate healing.
Choice B rationale: Hydrogel dressings are typically used for wounds with necrotic tissue or those that require a moist environment. They may not be the first choice for a stage I pressure ulcer with intact skin.
Choice C rationale: Wet-to-dry dressings are often used for wounds with debris or infection. They involve placing moist gauze into the wound and allowing it to dry, promoting debridement. This is not suitable for an intact stage I pressure ulcer.
Choice D rationale: Alginate dressings are absorbent and are more appropriate for wounds with moderate to heavy exudate. They may not be necessary for a stage I pressure ulcer with minimal or no exudate.
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