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

Explanation

Choice A rationale: During the emergent phase of burn management, patients commonly experience hemoconcentration due to fluid shift from the intravascular space to the interstitial space. This leads to an increase in hematocrit, indicating a higher concentration of red blood cells in the blood.
Choice B rationale: Burn injuries often result in increased protein breakdown and an elevation in BUN levels.
Choice C rationale: Burn injuries can cause the release of potassium from damaged cells, leading to hyperkalemia rather than hypokalemia.
Choice D rationale: The emergent phase of burn management is characterized by a decrease in serum albumin due to protein loss from the burned tissue and increased capillary permeability.

A. Alteration in activity tolerance B. Impaired tissue perfusion C. Impaired skin integrity D. Alteration in body image

Correct Answer is B

Explanation

Choice A rationale: While impaired tissue perfusion can affect activity tolerance, addressing the underlying perfusion issue takes precedence.
Choice B rationale: Varicose veins with ulcerations and lower extremity edema suggest impaired tissue perfusion. The compromised blood flow can lead to poor oxygenation and nutrient delivery to tissues, increasing the risk of ulceration and delayed wound healing.
Choice C rationale: Impaired tissue perfusion contributes to impaired skin integrity, but it is not the primary issue.
Choice D rationale: While varicose veins can impact body image, addressing impaired tissue perfusion is more critical for the client's overall well-being.

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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

The nurse is reviewing laboratory values for a patient receiving treatment during the emergent phase of burn management. Which laboratory result should the nurse expect for the patient at this time:

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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