A nurse is teaching clients on the need for calcium intake to prevent bone loss. What level of prevention does this represent?

Choice A reason: Assessing involves collecting data, like vital signs or skin condition, to identify patient needs. Turning a client every 2 hours follows an established plan to prevent pressure ulcers, not data collection. Assessment informs care plans, but turning is an action, not an evaluation of physiological status, making this incorrect.

Choice B reason: Planning involves setting goals and interventions, like scheduling turns to prevent pressure ulcers. Turning a client every 2 hours is executing that plan, not creating it. Planning addresses skin integrity and tissue perfusion needs, but the act of turning is the implementation phase, making this an incorrect choice.

Choice C reason: Implementing is the execution of the care plan, such as turning a client every 2 hours to prevent pressure ulcers. This action maintains skin integrity by reducing pressure on tissues, promoting blood flow and oxygenation. It follows the plan’s directives, aligning with the nursing process’s action phase, making this the correct choice.

Choice D reason: Evaluating assesses the effectiveness of interventions, like checking skin integrity after turning. Turning a client every 2 hours is the intervention itself, not its evaluation. Evaluation measures outcomes, like reduced pressure ulcer risk, but the act of turning is implementation, addressing tissue perfusion, making this incorrect.

Choice A reason: Instructing repositioning every 2 hours is appropriate but not the first action for a progressing ulcer, seen on video. Verification via in-person assessment ensures accuracy, as video may not capture depth or infection. A home visit confirms the stage, guiding intervention, per pressure ulcer management protocols.

Choice B reason: Asking the daughter to take pictures is unreliable, as non-professional images may lack clarity or accuracy. A nurse’s in-person assessment is needed to evaluate ulcer progression, ensuring proper staging and treatment, avoiding misdiagnosis, per telehealth and wound care standards.

Choice C reason: Contacting the provider for a hydrocolloid dressing is premature without verifying the ulcer’s stage in person. Stage 1 ulcers typically require pressure relief, not advanced dressings. A home visit confirms progression, ensuring appropriate intervention, per evidence-based wound care guidelines.

Choice D reason: Making a home visit to verify ulcer changes is the priority, as video may not fully capture progression (e.g., depth, infection). In-person assessment confirms the stage, guiding accurate treatment like dressings or repositioning, preventing deterioration, per telehealth wound assessment and pressure injury protocols.