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 C
Explanation
Choice A rationale
"Patient will ambulate for 15 minutes after lunch" is a planned nursing intervention or goal, outlining a future action for the patient. It describes what is expected to happen, not what has already been implemented and documented.
Choice B rationale
"Patient selected low-sugar snacks independently" describes an observation of the patient's behavior and adherence to a dietary plan. While it reflects an action, it doesn't explicitly document a direct nursing intervention performed.
Choice C rationale
"Patient was medicated with Tylenol 500 mg PO for pain" clearly documents the implementation of a specific nursing intervention – the administration of medication. It states what was done, including the drug, dosage, route, and reason.
Choice D rationale
"Patient participated in group therapy session without prompting" describes the patient's participation in a therapeutic activity. While nurses may facilitate or encourage participation, this statement focuses on the patient's action rather than a direct nursing intervention performed on the patient. .
Correct Answer is A
Explanation
Choice A rationale
The nursing process is a systematic, cyclical method used by nurses to identify and address patient health needs. It involves assessment, diagnosis, planning, implementation, and evaluation, providing a structured approach to problem-solving and the delivery of individualized care.
Choice B rationale
Standardized protocols offer guidelines for specific conditions but do not encompass the holistic and individualized nature of the entire nursing process. The nursing process allows for adaptation and critical thinking beyond pre-established routines to meet unique patient needs.
Choice C rationale
A legal document defining the scope of practice outlines what nurses are legally allowed to do. While the nursing process guides nursing actions, it is a framework for care delivery rather than a legal definition of professional boundaries.
Choice D rationale
While communication is integral to healthcare, the nursing process is more than just a communication tool. It is a comprehensive framework that guides all aspects of nursing care, from initial assessment to the evaluation of outcomes, involving critical thinking and clinical judgment.
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