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.

Answer and Explanation

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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Correct Answer is ["4"]

Explanation

To calculate the volume (mL) that the nurse should administer per dose, you can use the following formula:

Volume (mL) = Dose (units)/Concentration (units/mL)

In this case:

Volume = 400,000 units/100,000 units/mL
Volume=4mL

Therefore, the nurse should administer 4 mL of Mycostatin oral suspension per dose.

A. Flush the tube with 5 mL of water. B. Test the pH of fluid aspirated from the tube. C. Inject air through the tubing and auscultate for gurgling sounds: D. Change the bag and tubing system every 12 hr

Correct Answer is B

Explanation

A. Flush the tube with 5 mL of water:

Explanation: Flushing the tube with water is a routine practice before and after administering medications or feedings to maintain tube patency. However, it is not the primary action to confirm tube placement.

B. Test the pH of fluid aspirated from the tube (Correct Answer):

Explanation: Testing the pH of aspirated fluid helps confirm that the tube is in the stomach. A pH between 1 and 5 is generally indicative of gastric placement.

C. Inject air through the tubing and auscultate for gurgling sounds:

Explanation: This method is an older practice and is not recommended as a reliable method for verifying tube placement. Testing the pH is a more accurate and preferred method.

D. Change the bag and tubing system every 12 hr:

Explanation: Changing the bag and tubing system every 12 hours is a routine practice to maintain the integrity of the enteral feeding system. However, it is not specifically related to the initial steps in verifying tube placement.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer mycostatin 400,000 units PO every 6 hr. Available is mycostatin oral suspension 100,000 units/mL. How many ml should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["4"]

Explanation

A nurse is preparing to administer an intermittent enteral feeding through a small-bore NG tube. Which of the following actions should the nurse take before initiating the feeding?

Correct Answer is B

Explanation

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