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 D
Explanation
Choice A rationale: individuals with extensive burn wounds are highly likely to develop metabolic acidosis and not metabolic alkalosis due to the increased risk of tissue hypoxia, increased lactic acid levels, and renal failure.
Choice B rationale: low hemoglobin is not an expected finding in individuals with extensive burn wounds but instead increased hemoglobin levels are expected due to hemoconcentration resulting from excessive fluid loss.
Choice C rationale: A patient with extensive burn wounds is expected to have hypovolemia and not hypervolemia due to increased fluid loss from the burned tissues and increased capillary permeability.
Choice D rationale: hyperkalemia is a common finding in individuals with extensive burn wounds due to massive cell destruction which releases potassium from the intracellular compartment to the extracellular compartment.
Correct Answer is A
Explanation
Choice A rationale: Erythema (redness) is the first indication of a superficial burn injury. Superficial burns, also known as first-degree burns, involve only the outer layer of the skin and are characterized by redness without blistering.
Choice B rationale: Eschar is associated with deeper burns and is not the first indication of a superficial burn.
Choice C rationale: Blistering is associated with partial-thickness burns (second-degree burns) and does not occur in superficial burns.
Choice D rationale: Pain is typically present in superficial burns, and the absence of pain is not a characteristic of superficial burns.
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