A nurse is caring for a client who has major depressive disorder and is refusing their medication. The client's family suggests placing the client's medication in their food. Which of the following actions should the nurse take?

Rationale:

A. Asking the client to assist with a surgical dressing change following a total hip arthroplasty may be inappropriate due to the client's postoperative physical limitations and hip precautions. While fostering independence is generally positive, it does not specifically address the physiological age-related changes of the integumentary system. The primary concern in this scenario is protecting the integrity of the client's fragile skin during adhesive removal.

B. Waiting for a client to request assistance for a scheduled postoperative dressing change is a deviation from the standard plan of care and proactive nursing management. Postoperative wound care is a scheduled clinical priority to monitor for infection and promote healing. This action does not demonstrate sensitivity to age-related physiological changes and could potentially lead to delayed detection of surgical site complications or wound dehiscence.

C. Using paper tape is the most appropriate action because older adults possess a thinner stratum corneum and diminished cohesion between the dermis and epidermis. Traditional plastic or silk adhesives can cause epidermal stripping and skin tears upon removal due to their high tackiness. Paper tape provides sufficient securement for the surgical dressing while minimizing the risk of mechanical injury to the sensitive, translucent skin of an elderly patient.

D. Applying a dressing loosely over a fresh surgical incision is contraindicated as it fails to provide an adequate microbial barrier and does not support wound healing. A loose dressing may shift, causing friction against the incision line or allowing contaminants to reach the surgical site. To demonstrate age-related sensitivity, the nurse must ensure the dressing is secure while using materials that are gentle on the surrounding atrophic skin.

Answer: D

Rationale:

A) Collect 2 mL of sputum in an emesis basin: Collecting sputum in an emesis basin is inappropriate for laboratory testing. The sputum should be collected directly into a sterile container to prevent contamination. This ensures that the culture and sensitivity results are accurate and reflect the client's true respiratory pathogens.

B) Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection: Using an antiseptic mouthwash before collecting a sputum sample is not recommended because it may alter the flora present in the sputum, leading to inaccurate culture results. Instead, the client should rinse their mouth with plain water to clear excess saliva or food debris.

C) Swab the oropharynx with a sterile swab: Swabbing the oropharynx does not obtain sputum from the lungs but instead gathers a sample from the throat, which may not be reflective of lower respiratory infections. A proper sputum sample is produced through a deep cough to collect material directly from the lungs.

D) Refrigerate the specimen until the time of transport to the laboratory: Refrigerating the sputum specimen helps to preserve its integrity by preventing the overgrowth of bacteria or other pathogens until it can be transported to the laboratory. Proper refrigeration ensures that the culture and sensitivity results remain accurate.