A nurse is caring for a client who is disoriented and has removed their IV catheter. After observing the RN reinsert the IV catheter, which of the following actions should the nurse take first?

A) Select the appropriate dressing:

Choosing the appropriate dressing is an essential step in the process of changing a wound dressing. However, before selecting a dressing, the nurse should first review the available dressing types to ensure that the choice is based on a comprehensive understanding of the client's wound characteristics, such as size, depth, exudate level, and presence of infection. Jumping straight to selecting a dressing without reviewing available options may result in choosing an inadequate or inappropriate dressing for the client's specific wound care needs.

B) Review available dressing types:

This is the most appropriate initial step in the process of changing a wound dressing. Before proceeding with the dressing change, the nurse should assess the client's wound and review the available dressing types to determine which one is most suitable. Factors to consider include the wound's characteristics, such as size, depth, and exudate level, as well as any specific requirements based on the stage of the pressure ulcer and the client's overall condition. Reviewing available dressing types ensures that the nurse makes an informed decision and selects the most appropriate dressing for promoting wound healing and preventing complications.

C) Document the dressing change:

Documentation is an essential aspect of wound care, as it provides a record of the client's progress, the interventions performed, and the client's response to treatment. While documenting the dressing change is important, it should occur after the dressing change itself. Documenting before completing the dressing change could lead to incomplete or inaccurate documentation, as the nurse may need to record details about the wound's appearance, the type of dressing used, and any observations made during the procedure.

D) Change the dressing:

Changing the dressing is a necessary step in the wound care process, but it should not be the first action taken without assessing the wound and reviewing available dressing options. Proceeding directly to changing the dressing without considering the client's specific wound care needs and available dressing types may result in suboptimal wound management and compromise the client's healing process.

A) Turn off electrical equipment in the client's room: While turning off electrical equipment can help prevent the spread of fire if the source is electrical, it may not be the most immediate action to take after removing the client from the room. The priority is to activate the alarm to alert others and initiate the fire response protocol.

B) Use a Class A fire extinguisher to contain the fire: Using a fire extinguisher is a potential action, but the type of fire extinguisher needed depends on the type of fire. Class A fire extinguishers are suitable for ordinary combustibles such as wood and paper. However, since the source of the fire is a trash can, the fire may involve combustible materials beyond Class A. Therefore, activating the alarm takes precedence over extinguishing the fire.

C) Close the door to the client's room: Closing the door can help contain the fire and prevent its spread to other areas. While this action is important, it is secondary to activating the alarm, which alerts others to the fire and initiates the response process.

D) Activate the alarm outside the client's room: This is the most appropriate action to take first. Activating the alarm alerts others to the fire, enabling them to respond promptly and effectively. It initiates the facility's fire response protocol, including evacuating occupants and summoning the fire department. This action ensures the safety of everyone in the vicinity and allows for a coordinated emergency response.