During a bath, the nurse notices redness and a potential pressure ulcer on the client's sacral area. What should the nurse do next?

Apply a topical ointment and continue with the bath.

Cover the area with a bandage to prevent infection.

Document the findings and report to the healthcare provider.

Ignore it since it is a common issue in bedridden clients.

Answer and Explanation

The Correct Answer is C

A. Apply a topical ointment and continue with the bath: Applying ointment without further assessment or orders can mask skin changes and delay appropriate intervention. Early pressure injury management requires evaluation and interdisciplinary planning rather than routine topical treatment.

B. Cover the area with a bandage to prevent infection: Covering the area without assessment, staging, or provider notification may be inappropriate and could worsen skin breakdown. Dressing selection depends on the stage of the pressure injury and underlying skin integrity.

C. Document the findings and report to the healthcare provider: Redness over the sacral area may indicate a stage 1 pressure injury and requires prompt documentation and reporting. This allows for early interventions such as pressure redistribution, skin protection, and care plan updates before major damage occurs.

D. Ignore it since it is a common issue in bedridden clients: Pressure injuries are never expected or acceptable findings. Ignoring early signs increases the risk of progression to deeper tissue injury and serious complications.

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Correct Answer is B

Explanation

A. Rotating leadership roles daily among team members: While sharing leadership can promote skill development, daily rotation may create confusion and inconsistency in patient care responsibilities. Stable leadership enhances coordination and accountability in team nursing.

B. Assigning tasks based on each nurse's strengths and experience: Effective collaboration involves leveraging each team member’s skills and expertise to optimize patient care. Assigning tasks according to strengths ensures efficiency, safety, and high-quality care while promoting teamwork.

C. Limiting communication to scheduled meetings only: Restricting communication reduces opportunities to share critical patient information in real time, which can compromise care coordination. Continuous communication is essential for effective team nursing.

D. Having each nurse work independently on their assigned tasks: Independent work without collaboration may result in fragmented care, duplication of efforts, or missed information. Team nursing relies on shared responsibility and coordinated efforts to meet patient needs.

A. Place the client in a prone position to improve oxygenation B. Notify the provider and prepare for intubation C. Increase oxygen via nasal cannula to 2 L/min. D. Verify the reading and assess for signs of respiratory distress.

Correct Answer is D

Explanation

A. Place the client in a prone position to improve oxygenation: Prone positioning may improve oxygenation in certain critically ill patients, but it is not the first step for a client with an SpO₂ of 90%. Immediate assessment is necessary before changing position.

B. Notify the provider and prepare for intubation: While persistent hypoxemia may eventually require provider notification, intubation is not indicated without assessment of the patient’s overall respiratory status. Premature escalation can lead to unnecessary interventions.

C. Increase oxygen via nasal cannula to 2 L/min: Administering supplemental oxygen may be appropriate, but initiating treatment without assessing for accuracy of the reading and current signs of respiratory distress could mask underlying issues or result in improper dosing.

D. Verify the reading and assess for signs of respiratory distress: The priority action is to confirm the SpO₂ measurement and evaluate for signs of hypoxia, such as increased work of breathing, cyanosis, or altered mental status. Assessment guides safe, evidence-based interventions and ensures accurate clinical decision-making.

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During a bath, the nurse notices redness and a potential pressure ulcer on the client's sacral area. What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In a team nursing model, which of the following actions would best demonstrate effective collaboration among team members to enhance patient care?

Correct Answer is B

Explanation

A client's oxygen saturation is measured at 90% on room air. What action should the nurse take first?

Correct Answer is D

Explanation

A nurse is assessing a client's blood pressure using the two-step method. Which error could lead to inaccurate readings?

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When assessing a patient with dark skin tones for suspected deep tissue injury, what should the nurse prioritize?

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A nurse is working in a healthcare facility that uses critical pathways to manage patient care. Which action by the nurse demonstrates an understanding of when to deviate from the critical pathway?

The nurse observes a patient with a heart rate of 120 bpm and reports of dizziness. What is the nurse's next action?

A nurse is assessing a patient with suspected deep tissue injury on the sacral area. Which finding would most likely confirm this diagnosis?