A nurse is collecting data from a client who has a stage III pressure ulcer and requires a dressing change. Which of the following steps should the nurse take first?
Change the dressing.
Select the appropriate dressing.
Review available dressing types.
Document the dressing change.
The Correct Answer is C
A. Changing the dressing is an action that comes after assessing and selecting the appropriate dressing. Before changing the dressing, the nurse needs to gather information and make decisions about the most suitable type of dressing based on the characteristics of the wound.
B. Selecting the appropriate dressing is an essential step, but before doing so, the nurse should review available dressing types to make an informed decision about which dressing will best meet the needs of the wound. This involves considering factors such as the wound's characteristics, exudate level, and the overall condition of the client.
C. Reviewing available dressing types is the first step because it allows the nurse to assess the wound, gather information about the client's condition, and make an informed decision about the most appropriate dressing. This step ensures that the chosen dressing aligns with the wound's characteristics and promotes optimal healing.
D. Documenting the dressing change is an important step in the process, but it typically occurs after the dressing change has been completed. Documentation is crucial for tracking the client's progress, ensuring continuity of care, and providing a record for other healthcare team members.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Facility policy and procedure manual.
The facility policy and procedure manual is the primary resource for step-by-step directions to clean up a chemical spill within a specific healthcare setting. Each healthcare facility has its own policies and procedures outlining the appropriate steps to take in the event of a chemical spill to ensure the safety of both patients and healthcare providers.
B. Poison Control Center:
The Poison Control Center is a valuable resource for information related to poisoning, but it may not provide specific step-by-step directions for cleaning up a chemical spill. Its primary focus is on managing exposures and providing advice on the treatment of poisonings.
C. Safety data sheet (SDS):
The Safety Data Sheet provides information about the properties of a chemical substance. While it offers details about the chemical and its hazards, it is not typically used as a step-by-step guide for cleaning up a spill. The SDS is more focused on providing information about the chemical's properties, safety precautions, and emergency response measures.
D. The National Quality Forum:
The National Quality Forum is a healthcare organization that focuses on healthcare quality improvement. It is not a primary resource for specific step-by-step directions for handling a chemical spill. Facility-specific policies and procedures are more appropriate for this purpose.
Correct Answer is A
Explanation
A. Discard any remaining medication after 10 days:
This is the correct action according to the label. The label specifies that the reconstituted suspension should be discarded after 10 days, emphasizing the importance of not using the medication beyond that period for safety reasons.
B. Use 0.9% sodium chloride solution as a diluent:
The label does not mention the use of 0.9% sodium chloride solution. It specifically provides directions for adding water for reconstitution. Therefore, using sodium chloride solution is not consistent with the instructions.
C. Roll the vial gently in hands to mix the medication:
The label instructs to "Shake vigorously" to wet the powder, not to roll it gently. Shaking is the recommended method for mixing the medication according to the label.
D.Store the medication at room temperature following reconstitution:
The label clearly states that the reconstituted suspension "Must be refrigerated." Storing it at room temperature contradicts the provided instructions
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