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 ["3"]
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
- 165 lb×0.453592 kg/lb≈74.843 kg
Calculate the total dose using the weight and prescribed dose:
- Total Dose (units)=Dose per kg×Weight (kg)
- Total Dose=8 units/kg×74.843 kg≈598.744 units
Determine the volume using the concentration of the available solution:
- Volume (mL)=Total Dose (units)/Concentration (units/mL)
- Volume =598.744 units/200 units/mL ≈ 2.994 mL
Therefore, the nurse should administer approximately 3 mL of calcitonin for the 8 units/kg IM dose, rounded to the nearest whole number.
Correct Answer is ["C","D"]
Explanation
A. "I should wait until I am terminally ill to complete my advance directives."
This statement is incorrect. It is advisable to complete advance directives before a critical or terminal illness occurs to ensure that one's preferences are known and respected in the event of incapacity.
B. "I must name a relative to make decisions for me in my health care proxy."
This statement is incorrect. While naming a relative is a common choice, individuals can choose any competent person as their healthcare proxy, and it does not have to be a family member.
C. "I can state in my living will which medical treatments I want done if I am terminally ill."
This statement is correct. A living will allows individuals to specify the medical treatments they wish to receive or avoid in the event they become terminally ill or incapacitated.
D. "I will make changes to my advance directives if I change my mind about anything."
This statement is correct. Advance directives are not permanent and can be changed or updated if the individual's preferences or circumstances change.
E. "I will need to complete a new living will each time I am hospitalized."
This statement is incorrect. Advance directives, including living wills, are generally not tied to a specific hospitalization. They remain in effect unless the individual chooses to update or change them.
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