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?

A. A staff member places a midstream urine sample in a specimen refrigerator after collecting it:

This is a proper practice. Refrigerating the sample after collection helps preserve its integrity and prevents bacterial growth until it can be analyzed.

B. A staff member wipes a countertop with chlorhexidine solution to clean the area following a blood spill:

This is a proper infection control practice. Chlorhexidine is an effective disinfectant, and cleaning the area following a blood spill helps prevent the spread of infectious agents.

C. A nurse uses alcohol-based antiseptic to clean his hands after talking with a client who has varicella zoster:

This is a proper practice. Alcohol-based antiseptic is effective in killing a broad spectrum of germs, and hand hygiene is crucial, especially after contact with a client who may have an infectious condition.

D. A nurse pours sterile 0.9% sodium chloride irrigation solution on an open pressure wound prior to collecting a specimen for culture:

This is an infection control hazard. Sterile saline irrigation should not be poured onto an open wound before specimen collection, as it can introduce contaminants and interfere with the accuracy of culture results. Specimens should be collected using aseptic technique to avoid contamination.

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.