A nursing intervention directs the patient to be turned every 2 hours to prevent skin breakdown from immobility. Assessment findings on new reddened areas on the lateral aspects of the right knee and ankle are obtained.
What is the most appropriate way for these findings to be used when the care plan is evaluated?
a. The information will be added to the relevant area of the electronic medical record.
b. The nursing diagnosis will be changed from an actual problem to a potential problem.
c. The new intervention of calling the physician will be added to the care plan.
d. The intervention will change to have the patient turned every hour.
Question 2
The nurse is attempting to take the history of a newly admitted 92-year-old patient but is unable to obtain the information because of the patient's cognitive status. The nurse should
a. refuse to complete the admission without more information.
b. contact the family for information on the patient's history.
c. call the doctor in the emergency room for a history.
d. ask another nurse to try to obtain the information from the patient.
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