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: Pain management is a crucial aspect of care for a client with herpes zoster (shingles). Administering analgesics can help alleviate pain and improve the client's overall comfort.
Choice B rationale: Herpes zoster is not spread through respiratory droplets, so restricting visitors based on their vaccination status is not necessary.
Choice C rationale: Protective isolation is not required for herpes zoster, as it is not highly contagious.
Choice D rationale: There is no need to avoid alcohol-based hand rubs in the care of a client with herpes zoster.
Correct Answer is C
Explanation
Choice A rationale: Actinic keratosis presents as rough, scaly patches on sun-exposed skin and is not associated with the purplish-brown lesions seen in Kaposi's sarcoma.
Choice B rationale: Basal cell carcinoma typically presents as pearly or waxy bumps and is not characterized by widespread purplish-brown lesions.
Choice C rationale: Kaposi's sarcoma is characterized by the development of purplish-brown skin lesions, and it is commonly associated with advanced HIV/AIDS.
Choice D rationale: Toxic epidermal necrolysis is a severe skin reaction but is not typically associated with purplish-brown lesions.
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