A nurse is documenting the wound care provided to a client who has a pressure ulcer on the sacrum.

Which information should the nurse include in the documentation?

Document the error in the client's medical record and the incident report.

Rationale: The nurse should document the error in both the client's medical record and the incident report, as this is part of the legal and ethical responsibility of the nurse. The documentation should include the facts of what happened, what actions were taken, and the client's response.

Incorrect options:

B) Notify the client's physician and the risk management department. - This is not the most appropriate action, as the nurse should first report the error to the nurse manager, who will then decide who else needs to be notified and how to proceed with further investigation and follow-up.

C) Explain the error to the client and apologize sincerely. - This is not the most appropriate action, as the nurse should first ensure that the client is safe and stable, and then consult with the nurse manager and the legal department before disclosing the error to the client. The nurse should also avoid admitting fault or liability, as this could have legal implications.

D) Wait until the end of the shift to report the error. - This is not an appropriate action, as the nurse should report the error as soon as possible, preferably within an hour of its occurrence. Delaying reporting could compromise client safety and quality of care, as well as increase the risk of legal action.

All of the above

Rationale: The nurse should document all aspects of wound care, including the type and amount of dressing used, the location and size of the wound, and the appearance and odor of the wound. This information helps to monitor the healing process, evaluate the effectiveness of interventions, and identify any signs of infection or complications.

Incorrect options:

A) The type and amount of dressing used - This is an important information to document, but not the only one.

B) The location and size of the wound - This is an important information to document, but not the only one.

C) The appearance and odor of the wound - This is an important information to document, but not the only one.