accurate documentation of assessment findings regarding pressure ulcers is very important because
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Nursing Elites

NCLEX-PN

Nclex Questions Management of Care

1. Why is accurate documentation of assessment findings regarding pressure ulcers crucial?

Correct answer: D

Rationale: Accurate documentation of assessment findings regarding pressure ulcers is crucial because the nursing assessment of ulcers is a standard practice in nursing care. Documenting these findings not only ensures continuity of care but also plays a vital role in preventing further progression of the ulcer. Choices A, B, and C are incorrect because while laws, hospital policies, and physician requirements may influence documentation practices, the primary reason for accurate documentation lies in the standards of nursing practice and the quality of patient care.

2. Under what circumstances can an individual receive medical care without giving informed consent?

Correct answer: B

Rationale: An individual may receive medical care without giving informed consent in an emergency, life-or-death situation. This exception allows healthcare providers to provide immediate treatment to save a person's life or prevent serious harm when time is of the essence. Choices A, C, and D are incorrect because in all other situations, informed consent is required. The durable power of attorney for health care should be involved if available, the physician should have a discussion with the client in non-life-threatening situations, and in cases where clients are unable to speak for themselves, their designated representative or responsible party should be involved in the consent process.

3. An LPN is having a conflict with another nurse during her shift. She has tried to discuss the issues with the nurse with no resolution. What is the most appropriate way for the LPN to proceed?

Correct answer: B

Rationale: In this scenario, the most appropriate way for the LPN to proceed is to report the conflict to the assigned charge nurse of the unit. Following the chain of command is crucial in a professional setting to address conflicts effectively. Reporting the issue to the charge nurse, who is the immediate supervisor, allows for a structured approach to resolving the conflict. Reporting directly to higher levels such as the director of nursing or nurse manager may bypass the appropriate hierarchy and could create unnecessary tension. Attempting to resolve the issue independently with the other nurse may not be effective if previous attempts have failed, making it essential to involve the immediate supervisor.

4. What is involved in client education by the nurse?

Correct answer: B

Rationale: Client education by the nurse involves providing accurate and understandable information to the client. It is essential to offer relevant details without overwhelming them, making choice B the correct answer. Choice A is incorrect because providing excessive details can confuse the client rather than empower them with necessary knowledge. Choice C is incorrect as it is not the role of the nurse to question the reality of a client's pain; instead, they should address and manage the pain effectively. Choice D is incorrect as client education focuses on providing information and empowering clients with knowledge, not just administering medication.

5. Which fetal heart monitor pattern can indicate cord compression?

Correct answer: A

Rationale: Variable decelerations can indicate cord compression as they are caused by umbilical cord compression or prolapse. This pattern shows an abrupt decrease in heart rate with an erratic shape, often resembling a V or W. Early decelerations (choice B) are typically caused by head compression during contractions and are considered benign. Bradycardia (choice C) is a consistent low heart rate below 110 bpm and is not specific to cord compression. Tachycardia (choice D) is an abnormally high heart rate above 160 bpm and is not associated with cord compression.

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