The nurse is caring for an unconscious patient.
The nurse repositions the patient at least every 2 hours and ensures that all of the patient's bony prominences are padded.
What is the rationale for these actions?
Nursing regulations do not allow these care tasks to be delegated to unlicensed personnel.
The nurse identifies the patient care areas in which additional assistance is required.
The nurse realizes the potential for pressure injuries and acts to prevent their development.
The nurse is following the standing orders listed in the patient's medical record.
The Correct Answer is C
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Using correction tape is inappropriate as it obscures the original entry, violating the principle of maintaining a clear and accurate audit trail. This makes it impossible to determine what the original error was and who made it, which is crucial for accountability and legal purposes in healthcare documentation.
Choice B rationale
Shredding the original forms and rewriting them is unacceptable because it completely eliminates the original record. This action could be interpreted as an attempt to conceal errors or misrepresent information, which carries significant legal and ethical implications in patient care documentation.
Choice C rationale
Blacking out the error with a thick marker obscures the original information, making it impossible to review the mistake and understand the context. This method does not allow for verification of the initial entry or tracking of the correction process, which is essential for maintaining accurate medical records.
Choice D rationale
Drawing a single line through the incorrect information, making the correction clearly beside it, and then initialing and dating the change maintains the integrity of the original record while indicating who made the correction and when. This method ensures transparency and accountability in documentation, adhering to legal and professional standards for error correction in medical charts.
Correct Answer is C
Explanation
Choice A rationale
The physician is responsible for medical diagnoses, which identify diseases or medical conditions based on the patient's signs, symptoms, and diagnostic test results. While nurses use medical diagnoses to inform their care, they do not analyze data to arrive at them.
Choice B rationale
The patient provides subjective data about their health status, which is crucial information for the nurse's assessment. However, the patient does not have the clinical knowledge and expertise to analyze and interpret this data in the context of other findings to formulate a nursing diagnosis.
Choice C rationale
The nurse is responsible for collecting, analyzing, and interpreting patient data (both subjective and objective) to identify patterns, draw conclusions about the patient's health status, and formulate nursing diagnoses. Nursing diagnoses describe the patient's responses to actual or potential health problems that nurses are qualified and licensed to treat.
Choice D rationale
Therapists, such as physical therapists, occupational therapists, or respiratory therapists, focus on specific aspects of the patient's rehabilitation and treatment based on their area of expertise. While they contribute valuable data to the patient's overall care, they are not primarily responsible for formulating nursing diagnoses.
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