The nurse is using home telehealth monitoring to manage care for an 80-year-old who is homebound. The client spends most of their time in bed. Two weeks ago, the nurse detected sacral redness. Last week, it was classified as a Stage 1 pressure ulcer. On this visit, the nurse assesses the sacral area using a video camera, comparing it to the previous visit. Upon noting progression, what should the nurse do next?
Instruct the home health aide to reposition the client every 2 hours while awake.
Ask the client’s daughter to take pictures of the area and send them to the nurse.
Contact the health care provider to prescribe a hydrocolloid dressing.
Make a home visit to verify the changes in the ulcer.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: In SBAR (Situation, Background, Assessment, Recommendation), chest pain is part of the Situation (S), describing the current issue. Background (B) includes relevant medical history, like angina, which causes chest pain due to myocardial ischemia from reduced coronary blood flow. Chest pain is the presenting symptom, not historical context, making it incorrect for B.
Choice B reason: Pulse rate of 108 is part of the Assessment (A) in SBAR, reflecting current vital signs. Background (B) provides historical context, such as the patient’s angina diagnosis, which predisposes to myocardial ischemia. Tachycardia may result from pain or hypoxia but is a current finding, not historical data, making it incorrect for B.
Choice C reason: History of angina is the Background (B) in SBAR, providing relevant medical history. Angina, caused by coronary artery narrowing, reduces myocardial oxygen supply, leading to chest pain. This context informs the current episode of pain and tachycardia, guiding assessment and treatment, making it the correct data for the Background component.
Choice D reason: Oxygen is needed is part of the Recommendation (R) in SBAR, suggesting an intervention. Background (B) includes past medical history, like angina, which explains the patient’s predisposition to chest pain. Recommending oxygen addresses current hypoxia but is not historical data, making it inappropriate for the Background section of SBAR.
Correct Answer is C
Explanation
Choice A reason: The Quality and Safety Education for Nurses (QSEN) focuses on competencies like patient safety and quality improvement, not moral standards. It guides nursing education to enhance clinical skills and patient outcomes, addressing evidence-based practice and teamwork. Moral standards, involving ethical decision-making and professional conduct, are governed by the ANA Code of Ethics, not QSEN.
Choice B reason: The American Nurses Association Standards of Professional Performance outline behaviors like leadership and collaboration but focus on professional competence, not moral standards. These standards guide performance expectations, such as resource utilization and communication, rather than ethical principles like beneficence or autonomy, which are central to the ANA Code of Ethics for moral guidance.
Choice C reason: The American Nurses Association Code of Ethics provides moral standards for nursing, emphasizing principles like beneficence, nonmaleficence, autonomy, and justice. It guides ethical decision-making in patient care, addressing dilemmas like informed consent and confidentiality. This code ensures nurses uphold moral integrity in professional behavior, making it the correct guide for ethical standards.
Choice D reason: The American Nurses Association Standards of Practice define the nursing process (assessment, diagnosis, planning, etc.) but focus on clinical practice standards, not moral guidelines. These standards ensure competent care delivery but do not address ethical principles like patient autonomy or ethical dilemmas, which are covered by the ANA Code of Ethics.
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