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 ["0.71"]
Explanation
To calculate the volume (mL) of the reconstituted medication that the nurse should administer, you can use the following formula:
Volume (mL)=Desired Dose (mg)/Concentration (mg/mL)
In this case:
Volume = 250 mg/350 mg/mL
Now, let's calculate:
Volume = 250 mg/350 mg/mL
Volume=0.71mL
Therefore, the nurse should administer 0.71 mL of the reconstituted ceftriaxone solution to provide the prescribed dose of 250 mg, rounded to the nearest hundredth.
Correct Answer is A
Explanation
A. Complete an incident report.
Reporting a needlestick injury through an incident report is crucial. It documents the details of the incident, which is important for the nurse's safety and for initiating appropriate follow-up actions.
B. Receive a hepatitis C immunization:
There is no specific hepatitis C vaccine available. While there are vaccines for hepatitis A and hepatitis B, there is currently no vaccine to prevent hepatitis C. Seeking post-exposure prophylaxis and follow-up is more relevant in this case.
C. Notify the health department:
Notifying the health department might be necessary in some cases, but the immediate action for the nurse is to report the incident through an incident report within the facility. This allows for prompt internal investigation and necessary measures.
D. Start prophylactic antibiotic therapy:
Prophylactic antibiotic therapy is not the standard protocol for preventing hepatitis C transmission after a needlestick injury. Antiviral medications might be considered in certain cases for post-exposure prophylaxis for hepatitis C, but this decision should be made after consulting with a healthcare provider or infectious disease specialist based on the specific circumstances of the exposure. Reporting the incident remains the immediate priority.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.