A nurse is admitting an older adult client who is transferring from another facility.
The nurse notes pressure ulcers on the client's coccyx and abrasions around both wrists.
Which of the following actions should the nurse take to address suspicions of elder abuse?

Contact the family regarding the client's condition.

Notify risk management.

Inform the transferring agency of the client's condition.

Privately interview the client about the injuries.

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. Privately interview the client about the injuries.

Choice A rationale:

Contacting the family regarding the client’s condition might not be appropriate if the family is suspected of being involved in the abuse. It could potentially put the client at further risk.

Choice B rationale:

Notifying risk management is important for documentation and internal review, but it does not directly address the immediate need to assess and ensure the client’s safety.

Choice C rationale:

Informing the transferring agency of the client’s condition is necessary for continuity of care, but it does not address the immediate need to investigate the cause of the injuries and ensure the client’s safety.

Choice D rationale:

Privately interviewing the client about the injuries allows the nurse to gather more information about the cause of the injuries in a safe and confidential manner. This step is crucial in assessing the situation and determining if further action, such as reporting to authorities, is needed. It ensures the client’s safety and helps in identifying any potential abuse.

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Correct Answer is D

Explanation

Choice A rationale:

Expecting to have a rapid pulse rate for the first few weeks is not accurate information for a client with a newly implanted implantable cardioverter-defibrillator (ICD). After the ICD placement, the client's heart rate should stabilize within normal ranges. A consistently rapid pulse rate might indicate an issue with the device or the client's cardiovascular system, necessitating further evaluation.

Choice B rationale:

Returning in two weeks for a follow-up MRI is not advisable immediately after ICD placement. MRI (Magnetic Resonance Imaging) is contraindicated for individuals with ICDs due to the magnetic fields, which can interfere with the functioning of the device. The timing and necessity of any future MRI should be carefully planned and discussed with the healthcare provider in charge of the client's care.

Choice C rationale:

Resuming tub baths and swimming after 24 hours is not recommended after ICD placement. Submerging the ICD site in water, especially in the initial healing phase, can increase the risk of infection. Clients with newly implanted ICDs are usually advised to avoid submerging the device site in water for a specified period, as recommended by their healthcare provider.

Choice D rationale:

Wearing loose-fitting clothing is important advice for clients with newly implanted ICDs. Tight clothing, especially around the site of the device, can cause irritation and discomfort. Loose-fitting clothing ensures proper airflow to the site, reducing the risk of irritation and allowing for optimal healing. It is essential to provide this information to the client to promote comfort and prevent complications related to the ICD placement.

A. Apply a pressure dressing at the IV site. B. Place a warm, moist compress on the site. C. Express drainage from the IV site and send it to be cultured. D. Insert a new IV catheter distal to the discontinued IV site.

Correct Answer is B

Explanation

Choice A rationale:

Applying a pressure dressing at the IV site might be necessary after removing the catheter, but it does not address the inflammation and discomfort caused by phlebitis. Warm, moist compresses are more appropriate for this situation.

Choice B rationale:

Placing a warm, moist compress on the site is the correct action for phlebitis. Heat helps improve blood circulation, reduce inflammation, and provide relief from pain and discomfort. This choice addresses the client's condition effectively.

Choice C rationale:

Expressing drainage from the IV site and sending it for culture is not necessary in this context. Phlebitis is primarily an inflammatory condition, and drainage culture is not a standard practice for phlebitis.

Choice D rationale:

Inserting a new IV catheter distal to the discontinued IV site is not the immediate action to take for phlebitis. First, the nurse should address the inflammation and pain with warm compresses. If a new IV site is needed, it can be considered after managing the client's symptoms.

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A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client's coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning teaching for a client who has a newly implanted implantable cardioverter-defibrillator.Which of the following information should the nurse include?

Correct Answer is D

Explanation

A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at a peripheral IV site.Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

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A nurse is admitting an older adult client who is transferring from another facility.
The nurse notes pressure ulcers on the client's coccyx and abrasions around both wrists.
Which of the following actions should the nurse take to address suspicions of elder abuse?