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: Phototherapy can sometimes cause sensitivity to light, and wearing dark glasses can help protect the eyes from excessive light exposure.
Choice B rationale: It is not typical to interrupt phototherapy due to redness and tenderness, as some skin reactions may occur during treatment but can be managed without interruption.
Choice C rationale: The schedule of phototherapy can vary, and the choice of days on and off may not necessarily be fixed in a three-day pattern.
Choice D rationale: The frequency and timing of phototherapy sessions depend on the specific treatment plan prescribed by the healthcare provider.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale: radiation therapy is one of the possible management options for basal cell carcinoma (BCC) that uses high-energy rays to kill the cancerous cells.
Choice B rationale: this is incorrect since topical corticosteroids are ineffective in BCC management and may worsen the patient’s condition by suppressing their immune system.
Choice C rationale: micrographic surgery can be used in BCC management and it involves the removal of thin layers of skin to a point where no cancer cells can be detected.
Choice D rationale: this is appropriate and involves the use of electric current to burn off the cancer cells.
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