A nurse is performing an ongoing assessment for a client who has a pressure ulcer. Which of the following data should the nurse collect? (Select all that apply).

The size and depth of the ulcer.

The presence of drainage or odor.

The type and amount of pain medication administered.

The client's nutritional status and intake.

The client's level of mobility and activity.

Answer and Explanation

Correct Answer : A,B,D,E

Choice A reason:

The size and depth of the ulcer are important indicators of the severity and healing progress of the wound. The nurse should measure the length, width, and depth of the ulcer using a ruler or a probe and document the findings. The nurse should also note the presence of any undermining or tunneling in the wound bed.

Choice B reason:

The presence of drainage or odor can signal infection or necrosis in the wound. The nurse should assess the amount, color, consistency, and odor of the drainage and document the findings. The nurse should also culture the wound if indicated and initiate appropriate wound care interventions.

Choice C reason:

The type and amount of pain medication administered are not directly related to the assessment of the pressure ulcer. Pain is a subjective experience that varies among individuals and situations. The nurse should assess the client's pain level using a valid pain scale and administer analgesics as prescribed, but this is not part of the ongoing assessment of the wound itself.

Choice D reason:

The client's nutritional status and intake are vital factors that affect wound healing. The nurse should assess the client's weight, body mass index, serum albumin, prealbumin, and transferrin levels, and dietary intake of protein, calories, vitamins, minerals, and fluids. The nurse should also provide nutritional supplements or consult a dietitian as needed to optimize the client's nutritional status.

Choice E reason:

The client's level of mobility and activity are also important factors that influence wound healing. The nurse should assess the client's ability to move, reposition, and ambulate independently or with assistance. The nurse should also implement measures to reduce pressure, shear, and friction on the wound site, such as using pressure-relieving devices, turning and repositioning the client frequently, and providing skin care.

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Correct Answer is B

Explanation

Choice A reason:

Independent nursing interventions are actions that nurses can perform by themselves, without any management from a doctor or another discipline. For example, checking vital signs, repositioning a patient, or providing patient education are independent nursing interventions. These interventions do not require a health care provider's order.

Choice B reason:

Dependent nursing interventions are actions that nurses perform under the direction of a physician or as part of a care plan. For example, administering medications, performing diagnostic tests, or inserting an intravenous line are dependent nursing interventions. These interventions require a health care provider's order.

Choice C reason:

Collaborative nursing interventions are actions that nurses perform in coordination with other health care professionals, such as physicians, pharmacists, dietitians, or physical therapists. For example, developing a discharge plan, implementing a wound care protocol, or providing nutritional counseling are collaborative nursing interventions. These interventions may or may not require a health care provider's order, depending on the situation and the scope of practice of the nurse.

Choice D reason:

Evaluative nursing interventions are not a type of intervention, but rather a step in the nursing process. Evaluative nursing interventions are actions that nurses take to assess the outcomes of their care and the effectiveness of their interventions. For example, measuring pain levels, monitoring wound healing, or evaluating patient satisfaction are evaluative nursing interventions. These interventions do not require a health care provider's order.

A. "Do you have a family history of heart disease or stroke?.”. B. "How long have you been feeling this way?.”. C. "Are you taking any medications or supplements?.”. D. "What were you doing when the pain started?.".

Correct Answer is B

Explanation

Choice A reason:

Asking about family history of heart disease or stroke is not a priority question for a client who is experiencing chest pain and shortness of breath. This question may be relevant for assessing the client's risk factors, but it does not address the immediate problem or help to determine the cause of the symptoms. Therefore, this is not the best choice.

Choice B reason:

Asking how long the client has been feeling this way is a priority question for a client who is experiencing chest pain and shortness of breath. This question helps to determine the onset and duration of the symptoms, which are important factors for diagnosing and treating the client. For example, if the client has been feeling this way for more than 20 minutes, it may indicate a myocardial infarction (heart attack), which requires urgent intervention. Therefore, this is the best choice.

Choice C reason:

Asking about medications or supplements is not a priority question for a client who is experiencing chest pain and shortness of breath. This question may be relevant for assessing the client's medical history and possible drug interactions, but it does not address the immediate problem or help to determine the cause of the symptoms. Therefore, this is not the best choice.

Choice D reason:

Asking what the client was doing when the pain started is not a priority question for a client who is experiencing chest pain and shortness of breath. This question may be relevant for assessing the possible triggers or precipitating factors of the symptoms, but it does not address the immediate problem or help to determine the cause of the symptoms. Therefore, this is not the best choice.

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A nurse is performing an ongoing assessment for a client who has a pressure ulcer. Which of the following data should the nurse collect? (Select all that apply).

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Which type of intervention requires a health care provider's order?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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