A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close?

A. Relying on recall of information from past lectures and textbooks. Critical thinking involves applying knowledge, not just recalling it. Nurses must analyze patient-specific data and adapt care accordingly.

B. Using the nursing process. The nursing process (assessment, diagnosis, planning, implementation, evaluation) is a structured approach that guides clinical decision-making and ensures patient-centered care.

C. Drawing on past clinical experiences to formulate standardized care plans. Past experiences can inform decision-making, but care plans must be individualized to the patient’s current condition rather than relying solely on standardization.

D. Depending on the charge nurse to determine priorities of care. While charge nurses provide leadership, each nurse is responsible for critical thinking and independent decision-making based on their assessment.

A. Shortness of breath: While respiratory issues can reduce oxygenation and indirectly affect healing, shortness of breath is not a direct risk factor for pressure ulcer development.

B. Adequate dietary intake: Adequate nutrition prevents pressure ulcers rather than increasing the risk. Poor dietary intake, particularly protein and vitamin deficiencies, is a risk factor.

C. Decreased level of consciousness: Patients with a decreased level of consciousness (e.g., sedated, comatose, or confused patients) are at higher risk for pressure ulcers due to immobility, lack of repositioning, and unawareness of discomfort.

D. Muscular pain: While pain can limit movement, it is not a primary risk factor for pressure ulcer development. Immobility and prolonged pressure are the key contributors.