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 D

Explanation

A. The client requires additional help to stand:

While needing additional help to stand is relevant information, it may be expected in Parkinson's disease due to issues with mobility and balance. It is not an immediate priority unless it signals a significant change or poses an immediate risk.

B. The client has increased difficulty dressing:

Increased difficulty dressing is a common manifestation of Parkinson's disease and is important to address but may not be as urgent as issues related to swallowing.

C. The client reports insomnia:

Insomnia is a common issue in Parkinson's disease but may not be an immediate priority unless it significantly impacts the client's overall well-being or contributes to other health concerns.

D. The client has difficulty swallowing:

This is the correct answer. Difficulty swallowing (dysphagia) in Parkinson's disease is a serious concern as it can lead to complications such as aspiration pneumonia and malnutrition. It requires prompt attention and intervention to ensure the client's safety and prevent potential complications.

A. "A client can obtain a copy of their psychotherapy notes." B. I can remain logged-on to my computer if I step away for less than 5 minutes." C. I will ensure that my screen isn't visible to others when I'm documenting." D. "I will create a simple password that is easy to remember

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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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 in a long-term care facility is collecting data for an interdisciplinary care conference for a client who has Parkinson's disease. Which of the following findings is the priority for the nurse to report at the conference?

Correct Answer is D

Explanation

A charge nurse is reinforcing teaching with a newly licensed nurse about the confidentiality of clients' electronic health records. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is C

Explanation

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