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 A

Explanation

Fidelity: Fidelity refers to the concept of keeping promises and being faithful to commitments made to individuals. In this scenario, when the nurse states they will return as soon as possible with pain medication, they are making a commitment to the client and demonstrating fidelity by keeping that promise.

Justice: Justice pertains to fairness and the equitable distribution of resources. It is not directly related to the nurse's commitment to providing pain medication.

Autonomy: Autonomy involves respecting the individual's right to make decisions about their own care. While informing the client about the plan for pain medication is part of communication, the primary ethical principle being demonstrated here is fidelity.

Nonmaleficence: Nonmaleficence is the principle of doing no harm. While it is important in healthcare, the scenario described focuses more on the nurse's commitment to providing pain relief.

A. Shake the suspension well before each administration. B. Dilute the suspension with 38 mL water prior to initial use. C. Store the suspension in the refrigerator. D. Discard the suspension 14 days after opening the bottle

Correct Answer is A

Explanation

A. Shake the suspension well before each administration.

The medication label specifically states, "IMPORTANT: SHAKE WELL BEFORE EACH USE," and "THIS PRODUCT MUST BE SHAKEN WELL ESPECIALLY PRIOR TO INITIAL USE." This indicates the necessity of shaking the suspension before administration to ensure proper mixing of the medication.

B. Dilute the suspension with 38 mL water prior to initial use.

There is no indication on the label to dilute the suspension with water. The label emphasizes shaking well before use, but dilution is not mentioned.

C. Store the suspension in the refrigerator.

The storage instructions on the label state, "Store at 20° to 25°C (68° to 77° F) see USP controlled room temperature." Refrigeration is not mentioned, and it is not recommended to deviate from the specified storage conditions.

D. Discard the suspension 14 days after opening the bottle.

The label does not provide specific information about the shelf life after opening. Therefore, it is essential to follow the specific instructions on the label or refer to the package insert for complete prescribing information regarding the expiration or discard date after opening. The information on the label does not specify a 14-day limit.

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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

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