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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["12"]
Explanation
To calculate the volume (mL) that the nurse should administer, you can use the following formula:
Volume (mL) = Dose (mg)/Concentration (mg/mL)
In this case:
Volume = 300 mg/ (125mg/5 mL)
First, simplify the fraction:
Volume = 300 mg/25 mg/mL
Now, determine the volume:
Volume =(300 mg/25mg/mL) × (1mL/1mg)
Volume=12mL
Therefore, the nurse should administer 12 mL of phenytoin oral suspension for the 300 mg PO dose, rounded to the nearest whole number.
Correct Answer is C
Explanation
A. "A client can obtain a copy of their psychotherapy notes":
This statement is incorrect. Psychotherapy notes are generally not accessible to clients without specific authorization.
B. "I can remain logged-on to my computer if I step away for less than 5 minutes":
This statement is incorrect. It is essential to log off from the computer when stepping away to protect the confidentiality of client information.
C. "I will ensure that my screen isn't visible to others when I'm documenting":
This is the correct answer. Ensuring that the computer screen is not visible to others is an important practice to maintain confidentiality. It prevents unauthorized individuals from accessing sensitive client information.
D. "I will create a simple password that is easy to remember":
This statement is not recommended. Passwords should be strong and secure to protect against unauthorized access. Using a simple and easily guessable password compromises the confidentiality of electronic health records.
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