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) Reinforcing teaching with a client about stool specimen collection:

This task involves providing education to the client, which requires nursing knowledge and judgment. It is not appropriate to delegate to assistive personnel, as they may not have the necessary training or expertise to provide accurate and comprehensive teaching.

B) Collecting a urine specimen from a client who is experiencing dysuria:

Collecting a urine specimen from a client who is experiencing dysuria is an appropriate task to delegate to assistive personnel. This task involves following a standard procedure for specimen collection and does not require specialized nursing judgment or assessment skills.

C) Taking the vital signs of a client who is experiencing acute angina:

Assessing vital signs, especially in a client experiencing acute angina, requires nursing judgment and the ability to recognize and respond to changes in the client's condition. This task should not be delegated to assistive personnel, as they may not have the training to recognize signs of deterioration or respond appropriately.

D) Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure:

Providing information over the phone regarding NPO (nothing by mouth) status involves assessing the client's specific situation, understanding the procedure's requirements, and potentially making clinical decisions based on the client's condition. This task requires nursing judgment and should not be delegated to assistive personnel.