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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Related Questions
Correct Answer is C
Explanation
A. Report the occurrence to the nursing supervisor:
While reporting the occurrence is important, verifying the DNR status takes precedence. The nurse needs to gather information and confirm whether the patient has a current DNR order before escalating the issue to a higher authority.
B. Complete an incident report stating the facts of the situation:
Completing an incident report is a part of the process, but it should not be the first action. The immediate concern is to determine if the patient has a valid DNR order. An incident report can be completed later to document the situation and any actions taken.
C. Verify the DNR prescription is current in the medical record.
Verifying the DNR (do-not-resuscitate) prescription is the first and most immediate action the nurse should take. It is crucial to confirm the current status of the DNR order to ensure that the healthcare team is following the patient's wishes. If the DNR is indeed valid and up-to-date, it means the resuscitation efforts, including CPR, were contrary to the patient's expressed wishes.
D. Request a meeting with the ethics committee:
Contacting the ethics committee may be necessary depending on the circumstances, but it is not the first step. Verifying the DNR status is an immediate action that can guide subsequent decisions. If there are ethical concerns or conflicts, involving the ethics committee can be considered after confirming the facts surrounding the DNR order.
Correct Answer is C
Explanation
A. While reporting the fire details to the facility emergency extension is important, the immediate action to ensure the safety of everyone in the facility is to activate the fire alarm. Activating the fire alarm alerts the entire facility to the presence of a fire and initiates the appropriate emergency response.
B. Closing the door to the client's room is a secondary action and can be done after activating the fire alarm. However, the priority is to activate the fire alarm to quickly notify others about the potential danger.
C. Activating the fire alarm is the immediate action to take in the event of a fire. This step ensures that the fire response team is alerted, and appropriate emergency measures are initiated promptly.
D. Turning off electrical equipment can be a safety measure, but it is not the first priority when there is an active fire. Activating the fire alarm and ensuring the evacuation of individuals from the area take precedence.
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