Which nursing observation indicates a patient is at risk for pressure injury (PI) formation?

A. Administer a sleep medication to help the patient rest: Administering a sleep aid does not address the patient’s acute chest pain, which could indicate myocardial ischemia or another serious cardiac event. Sedation without pain assessment and intervention may mask critical symptoms, delaying life-saving care and putting the patient at risk for complications.

B. Educate the patient about the importance of reporting chest pain immediately: Prompt recognition and reporting of chest pain are essential for timely intervention, particularly to prevent myocardial damage or cardiac arrest. The nurse’s priority is to ensure the patient understands that early reporting can save lives, while also assessing and managing the pain.

C. Respect the patient's wishes and wait for the patient to ask for help: While patient autonomy is important, delaying assessment or intervention for severe chest pain compromises patient safety. Pain rated 8/10, especially in the chest, is a potentially emergent symptom that requires immediate evaluation regardless of the patient’s reluctance to “complain.”

D. Document the patient is not a complainer in the medical record: Documentation of patient personality traits does not address the urgent clinical situation. Proper documentation should reflect the severity of the pain, patient statements about symptoms, and the nursing interventions performed, focusing on safety rather than subjective characterizations.

A. Sharing patient information with another student: Sharing patient information without proper authorization violates HIPAA and patient confidentiality regulations. Discussing identifiable health information outside of approved educational or clinical contexts exposes the patient to privacy breaches and the student and facility to legal and ethical consequences.

B. Reviewing the patient's medical record: Reviewing a patient’s medical record is an appropriate activity for learning and care planning, provided the student has legitimate access and the purpose is related to patient care or educational objectives. This practice is expected in clinical training and does not compromise patient confidentiality.

C. Documenting medication administered to the patient: Documentation is a standard nursing responsibility, and students may document under supervision as part of clinical learning. Proper documentation ensures continuity of care and accuracy in the medical record, making this a correct and safe behavior.

D. Reading the patient's plan of care: Reviewing the plan of care helps students understand nursing interventions, goals, and patient needs. Accessing this information for educational purposes within the clinical setting is appropriate and supports safe, informed care delivery, and does not require preceptor intervention.