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: When removing personal protective equipment (PPE) after a procedure involving contact precautions, the nurse should remove the items in a specific order to minimize the risk of contamination. Gloves should be removed first because they are the most likely to be contaminated and can transfer microorganisms to other surfaces or PPE during removal.
Choice B rationale: The mask should be removed after gloves and gown. Removing the mask first could potentially contaminate the hands, leading to the risk of transferring microorganisms to the face during mask removal.
Choice C rationale: The gown should be removed after gloves and before the mask. Removing the gown too early could lead to potential contamination of the hands.
Choice D rationale: The face shield should be removed after gloves, mask, and gown. It provides additional protection for the face and should be retained until the end of the removal process to minimize the risk of contamination.
Correct Answer is A
Explanation
Choice A rationale: A superficial wound with no exudate (fluid drainage) can benefit from a film dressing. Film dressings are transparent, adhesive, and provide a protective barrier while allowing visualization of the wound. They are suitable for wounds with minimal or no drainage.
Choice B rationale: Foam dressings are often used for wounds with moderate to heavy exudate. They provide absorption and insulation but may not be the best choice for a wound with no exudate.
Choice C rationale: Alginate dressings are absorbent and suitable for wounds with moderate to heavy exudate. They may not be necessary for a superficial wound with no drainage.
Choice D rationale: Hydrofiber dressings are absorbent and can handle moderate to heavy exudate. Like alginate dressings, they may not be the most appropriate choice for a wound with no exudate.
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