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 A
Explanation
Choice A rationale: the epidermis becomes thinner and more fragile with age hence making the skin of elderly individuals more prone to injury, bruising, and infections.
Choice B rationale: this is incorrect because the skin in old age loses its elasticity and becomes more wrinkled due to the loss of collagen and elastin fibers responsible for maintaining the elasticity of the skin.
Choice C rationale: subcutaneous tissue comprising mainly of fat and connective tissue increases with age especially in regions such as the abdomen.
Choice D rationale: blood vessels within the skin become narrower and less efficient with increasing age thus resulting in decreased blood flow and oxygen delivery to the skin.
Choice E rationale: sebum production which is responsible for skin lubrication increases with age thus making this statement incorrect.
Correct Answer is ["325"]
Explanation
In burns, half the total fluids required within 24 hours should be given within 8 hours and the other half distributed over the remaining 16 hours to prevent hypovolemic shock and electrolyte imbalance.
Therefore, half the fluid that should be given within 8 hours is 5200/2= 2600
We will use the formula: drip rate= total volume of fluid to be administered/total duration
= 2600/8
=325 mL/hr
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