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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.7"]
Explanation
To calculate the volume (mL) that the nurse should administer, we can follow these steps:
Convert the weight from pounds to kilograms.
1 lb=0.453592 kg.
66 lb×0.453592 kg/lb≈29.937 kg
Calculate the total dose using the weight and prescribed dose:
Total Dose (mg)=Dose per kg×Weight (kg)
Total Dose=0.55 mg/kg×29.937 kg≈16.465 mg
Determine the volume using the concentration of the available solution:
Volume (mL) =Total Dose (mg)/Concentration (mg/mL)
Volume=16.465mg/25 mg/mL≈ 0.6586 mL
Therefore, the nurse should administer approximately 0.7 mL of chlorpromazine for the 0.55 mg/kg IM dose, rounded to the nearest tenth.
Correct Answer is C
Explanation
Hot tea:
Hot tea may not be well-tolerated by individuals experiencing chemotherapy-induced nausea, as hot or strong-smelling foods and beverages can be triggers. It is generally recommended to choose foods at room temperature.
Soft-serve ice cream:
Soft-serve ice cream may be too cold and could exacerbate nausea or discomfort. Cold foods might not be well-tolerated during or after chemotherapy.
Raisin toast:
This is the correct answer. Raisin toast is a good choice as it is a bland and easily digestible carbohydrate. It can be a suitable option for individuals experiencing nausea, providing some calories without strong odors or flavors.
String cheese:
While cheese can be a good source of protein, string cheese might not be the best choice if the individual is experiencing nausea, as the smell or taste of certain cheeses can be strong and trigger nausea.
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