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: Basal cell carcinoma commonly presents as a small, translucent papule with rolled borders. It may have a pearly or shiny appearance and often develops on sun-exposed areas, such as the nose.
Choice B rationale: This description is more characteristic of melanoma, not basal cell carcinoma.
Choice C rationale: This description may be more indicative of squamous cell carcinoma.
Choice D rationale: This description does not align with the typical presentation of basal cell carcinoma.
Correct Answer is A
Explanation
Choice A rationale: the epidermis which is the most superficial layer of the skin relies on the dermis for nutrition since it lacks its own blood supply.
Choice B rationale: adipose tissue is contained in the hypodermis which is part of the dermis layer of the skin and not the epidermis.
Choice C rationale: nerve fibers are contained in the dermis layer of the skin and not the epidermis.
Choice D rationale: blood vessels are contained in the dermis layer of the skin and not the epidermis.
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