The laboratory technician must have had a hard time getting the blood sample drawn as the patient's arm is now bruised.
The patient developed a large hematoma where the laboratory technician had drawn blood earlier in the shift.
Which statement is appropriate to enter in the patient's chart?

Choice A rationale

While nursing regulations do outline standards of care, the primary rationale for frequent repositioning and padding is not solely based on delegation limitations. Preventing pressure injuries is a fundamental nursing responsibility, regardless of who performs the tasks under appropriate supervision.

Choice B rationale

Identifying patient care areas needing additional assistance is a separate aspect of nursing assessment and care planning. While repositioning and padding contribute to overall well-being, their direct rationale is the prevention of skin breakdown, not the identification of staffing needs.

Choice C rationale

Unconscious patients are at high risk for developing pressure injuries due to immobility and decreased sensation. Repositioning at least every two hours reduces prolonged pressure on bony prominences, and padding distributes pressure more evenly, both crucial interventions in preventing tissue ischemia and subsequent ulcer formation.

Choice D rationale

While standing orders may include guidelines for repositioning and skin care, the underlying rationale stems from the physiological need to prevent pressure injuries in immobile patients. The nurse's actions are based on established principles of preventing complications associated with immobility, not solely on following pre-written orders. .

Choice A rationale

Setting priorities involves deciding the order in which nursing interventions should be implemented based on the urgency and importance of the client's needs. While addressing pain is often a high priority, the term itself doesn't specifically describe the cognitive process of interpreting nonverbal cues as pain.

Choice B rationale

Recognizing inconsistencies involves identifying discrepancies between verbal and nonverbal cues, or between the client's stated condition and observed behaviors. While the nurse is observing nonverbal cues, the primary action here is interpreting those cues, not necessarily identifying inconsistencies.

Choice C rationale

Making inferences involves interpreting cues and drawing conclusions based on available data. The nurse observes the client's moaning, clenched hands and teeth, and diaphoresis, and infers that these signs indicate the presence of pain. This interpretation then guides the decision to administer an analgesic.

Choice D rationale

Using empathy involves understanding and sharing the feelings of another person. While empathy is important in nursing care and may contribute to the nurse's interpretation of the client's distress, the specific cognitive process of interpreting the nonverbal cues as pain is termed making inferences.