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 B

Explanation

A. Agree on a desired outcome:

Before agreeing on a desired outcome, it is important to collect relevant facts and information about the situation. Understanding the specifics of the case is crucial for making informed decisions.

B. Collect the relevant facts:

This is the correct answer. Gathering information and understanding the facts surrounding the situation is the initial step in addressing any ethical dilemma. This includes understanding the nature of the medical treatment, reasons for refusal, and potential consequences for the child.

C. Examine personal values:

While personal values are important to consider, examining personal values typically comes later in the ethical decision-making process. The nurse first needs to understand the facts and the context of the situation.

D. Create a plan of action:

Creating a plan of action should be based on a thorough understanding of the situation, including the relevant facts and considerations. It is a step that follows the collection of information.

A. Ensure the client wears nonskid slippers when walking around the house. B. Attach full-length side rails to the client's bed. C. Install a raised toilet seat in the client's bathroom. D. Encourage an annual review of the medications the client is taking. E. Place throw rugs on uncarpeted floors in the client's home.

Correct Answer is ["A","C","D"]

Explanation

Ensure the client wears nonskid slippers when walking around the house.

Explanation: Nonskid slippers provide better traction and stability, reducing the risk of slipping.

B.Attach full-length side rails to the client's bed.

Explanation: Side rails can pose a risk of entrapment and may not prevent falls. The use of side rails is associated with safety concerns, and their use should be carefully evaluated.

C.Install a raised toilet seat in the client's bathroom.

Explanation: A raised toilet seat makes it easier for the client to sit down and stand up, reducing the risk of falls in the bathroom.

D.Encourage an annual review of the medications the client is taking.

Explanation: Medication reviews help identify drugs that may increase the risk of falls or interactions that could affect balance or cognitive function.

E.Place throw rugs on uncarpeted floors in the client's home.

Explanation: Throw rugs can be tripping hazards, especially for older adults with mobility issues. It's safer to have clear, unobstructed pathways in the home.

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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 assisting with the plan of care for a child whose parents refuse to accept the medical treatment prescribed by the provider. Which of the following actions should the nurse plan to take first to address this ethical dilemma?

Correct Answer is B

Explanation

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Correct Answer is ["A","C","D"]

Explanation

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