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

This client has undergone a paracentesis for ascites, and since it was done 4 hours ago, they are likely stable and can be considered for discharge.

The client who is 6 hours postoperative following a hip arthroplasty may still require close monitoring and postoperative care. Discharging a postoperative client too early could lead to complications.

The client with a blood glucose level of 380 mg/dL receiving insulin via IV infusion requires ongoing monitoring and management of their diabetes. Discharging this client during an external disaster may not be appropriate due to the need for continued medical intervention.

The client with pneumonia receiving 100% oxygen via a nonrebreather mask likely requires continued medical attention and monitoring. Discharging a client with pneumonia who requires high-flow oxygen can pose risks to their respiratory status.

A. Use an air-assisted device. B. Position the bed in reverse Trendelenburg. C. Elevate the head of bed to a 45° angle. D. Lower the bed close to the ground.

Correct Answer is A

Explanation

A. Use an air-assisted device.

Using an air-assisted device, such as a hover mat or air mattress, is an appropriate measure when repositioning a client with a pressure ulcer. These devices help reduce friction and shear forces, minimizing the risk of further skin breakdown. It also aids in maintaining the skin's integrity during movement, making it a suitable choice for the prevention of pressure ulcers.

B. Position the bed in reverse Trendelenburg:

Positioning the bed in reverse Trendelenburg involves raising the foot of the bed higher than the head. This position is not specifically related to pressure ulcer prevention or repositioning. It may be used for other medical reasons, but it does not directly address the issue of pressure ulcer care.

C. Elevate the head of bed to a 45° angle:

While elevating the head of the bed is commonly used for various reasons, including respiratory support or preventing aspiration, it may not be directly related to the repositioning of a client with a pressure ulcer. The angle mentioned (45°) is not specifically associated with pressure ulcer care.

D. Lower the bed close to the ground:

Lowering the bed close to the ground may be a safety measure to prevent injuries from falls, but it does not address the specific needs of repositioning a client with a pressure ulcer. The focus in pressure ulcer care is typically on using appropriate devices and techniques to minimize friction and pressure on vulnerable areas of the skin.

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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 selecting clients for discharge due to a local external disaster. Which of the following clients should the nurse recommend for discharge?

Correct Answer is A

Explanation

A nurse is reviewing safety precautions with an assistive personnel (AP) about repositioning a client who has a pressure ulcer. Which of the following actions suggested by the AP indicates an understanding of the procedure?

Correct Answer is A

Explanation

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