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Apply a topical ointment and continue with the bath: Applying ointment without further assessment or orders can mask skin changes and delay appropriate intervention. Early pressure injury management requires evaluation and interdisciplinary planning rather than routine topical treatment.

Cover the area with a bandage to prevent infection: Covering the area without assessment, staging, or provider notification may be inappropriate and could worsen skin breakdown. Dressing selection depends on the stage of the pressure injury and underlying skin integrity.

Ignore it since it is a common issue in bedridden clients: Pressure injuries are never expected or acceptable findings. Ignoring early signs increases the risk of progression to deeper tissue injury and serious complications.

Request specific recommendations from the provider: This step occurs later during the Recommendation portion of ISBARR. At the beginning of the communication, the nurse must first clearly state why the call is urgent before asking for orders or guidance.

Read back the orders given by the provider for clarification: Read-back occurs at the end of the communication to confirm accuracy of orders. It is not appropriate until recommendations have been made and instructions received.

Provide detailed background information including medical history: Background information follows the situation and should be concise. Providing extensive history too early can delay recognition of a life-threatening change in the client’s condition.

Interpreting lab results and making clinical decisions based on them: Interpretation of diagnostic data and independent clinical decision-making fall within the RN’s scope of practice. The LVN may review results but must not analyze or act on them independently.

Administering intravenous medications without supervision: IV medication administration often requires RN oversight and varies by facility policy and state regulations. Performing this independently exceeds the typical LVN scope in many settings.

Developing the initial care plan for a new patient: Creating the initial nursing care plan is an RN responsibility because it requires comprehensive assessment and clinical judgment. The LVN may contribute data but does not independently develop the plan.

To focus solely on verbal communication: Relying only on verbal communication can lead to misunderstanding, especially when health literacy is limited. Effective assessment requires using multiple strategies such as visual aids and teach-back to confirm understanding.

To disregard any cultural considerations: Cultural factors strongly influence how clients perceive health information and communicate. Ignoring these considerations can create barriers to understanding and reduce the effectiveness of the assessment.

To educate the client using written methods only: Written materials alone are often ineffective for clients with limited health literacy. Education should be adapted using simple language, verbal explanation, and demonstration rather than relying solely on written content.

Administer supplemental oxygen immediately: Oxygen may be needed, but it should follow a rapid assessment unless the patient is clearly unstable. Administering oxygen without assessment may mask the underlying cause of tachypnea.

Document the finding and notify the provider: Documentation and notification are important, but they are secondary to assessing the patient’s current respiratory status and identifying urgent signs of deterioration.

Encourage the patient to breathe deeply and slowly: This may be appropriate for anxiety-related tachypnea, but the cause of the increased respiratory rate must be assessed first to rule out hypoxia or acute respiratory compromise.

Supine: Remaining in the supine position places prolonged pressure on the sacrum, heels, and occiput, increasing the risk for pressure ulcer development in patients who cannot reposition themselves.

Trendelenburg: This position increases pressure and shear forces on the sacral area and is not recommended for pressure ulcer prevention, especially for immobile patients.

Prone: While it offloads pressure from the back, the prone position is difficult to maintain, uncomfortable for most patients, and increases pressure on the face, chest, and knees.

Administer IV fluids to stabilize heart rate: IV fluids may be indicated if hypovolemia is suspected, but giving fluids without assessing the underlying cause could be inappropriate and potentially harmful. Assessment must guide interventions.

Encourage the patient to lie and rest: While resting may temporarily relieve symptoms, it does not address the underlying cause. Immediate rest alone does not ensure patient safety if the tachycardia is due to a serious condition.

Notify the provider immediately: Provider notification may be necessary after assessment, but the nurse must first gather critical information to report, including vital signs, symptoms, and potential causes, to ensure effective communication and safe care.

Immediately close the wound with sutures to prevent infection: Primary closure of a contaminated wound increases the risk of infection because bacteria may be trapped inside. Immediate closure is inappropriate in wounds that are not clean or are at high risk for contamination.

Apply a hydrocolloid dressing to maintain a moist environment: Hydrocolloid dressings are suitable for clean or minimally exudative wounds. For contaminated wounds planned for tertiary intention, the priority is drainage and infection control, which may not be achieved with an occlusive dressing.

Use mechanical debridement to remove necrotic tissue daily: While debridement is important for necrotic tissue removal, routine daily mechanical debridement may damage healthy tissue. The primary focus in delayed primary closure is infection prevention and monitoring, rather than aggressive debridement.

Absence of red reflex: Absence of a red reflex indicates media opacity (e.g., cataract) or retinal abnormality, not necessarily oculomotor nerve function. This finding is unrelated to cranial nerve III integrity.

Pupils remain fixed and non-reactive: Fixed, non-reactive pupils suggest oculomotor nerve damage or severe intracranial pathology affecting parasympathetic fibers. This indicates impaired cranial nerve III function.

Pupils dilate in response to light: Normally, pupils constrict in response to light. Dilation instead of constriction indicates oculomotor nerve compromise or sympathetic overactivity, reflecting impaired parasympathetic control.

Administering medication from the nurse's personal supply: Administering prescription medication outside of a formal healthcare setting can exceed the scope of Good Samaritan protections and may be considered practicing without authorization.

Providing a ride to the hospital for the victim: Transporting a patient in a personal vehicle may create liability if harm occurs during transit. Good Samaritan laws typically do not cover providing personal transportation unless part of formal emergency response.

Offering legal advice to the victim regarding the accident: Providing legal advice is outside a nurse’s professional scope and is not covered under Good Samaritan protections. Only appropriate medical interventions performed in good faith are protected.