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 C

Explanation

A. While reporting the fire details to the facility emergency extension is important, the immediate action to ensure the safety of everyone in the facility is to activate the fire alarm. Activating the fire alarm alerts the entire facility to the presence of a fire and initiates the appropriate emergency response.

B. Closing the door to the client's room is a secondary action and can be done after activating the fire alarm. However, the priority is to activate the fire alarm to quickly notify others about the potential danger.

C. Activating the fire alarm is the immediate action to take in the event of a fire. This step ensures that the fire response team is alerted, and appropriate emergency measures are initiated promptly.

D. Turning off electrical equipment can be a safety measure, but it is not the first priority when there is an active fire. Activating the fire alarm and ensuring the evacuation of individuals from the area take precedence.

A. A client who reports experiencing short-term memory loss B. A client who is wearing urine-scented clothing C. A client who has fingernails that are discolored and broken D. A client who provides a detailed description of a recent fall at home

Correct Answer is B

Explanation

A. A client who reports experiencing short-term memory loss:

Memory loss is a common issue in older adults and does not necessarily indicate elder abuse. While it is a concern that should be addressed, it may not be related to abuse unless there are specific circumstances suggesting mistreatment.

B. A client who is wearing urine-scented clothing.

Wearing urine-scented clothing can be indicative of neglect, which is a form of elder abuse. Neglect occurs when the basic needs of an older adult, such as hygiene and cleanliness, are not adequately met. The nurse should report this finding to the case manager so that appropriate interventions and assessments can be made to address the potential abuse or neglect.

C. A client who has fingernails that are discolored and broken:

Fingernail issues can have various causes, including medical conditions or self-neglect. Discolored and broken fingernails alone may not be conclusive evidence of elder abuse, and further assessment is needed to determine the cause.

D. A client who provides a detailed description of a recent fall at home:

While falls are a concern, providing a detailed description of a fall is not necessarily indicative of elder abuse. Falls can occur for various reasons, and additional assessment is needed to determine the circumstances surrounding the fall and whether abuse or neglect is involved.

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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?

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