A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The nurse is preparing to change the client's surgical dressing. Which of the following actions should the nurse take to demonstrate sensitivity to age-related changes?
Ask the client to help with the dressing change
Wait for the client to approach the nurse for assistance
Use paper tape for securing the new dressing
Apply the dressing loosely over the incision
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The client has state-sponsored health insurance: While information about the client's health insurance coverage is important for billing and financial purposes, it may not be directly relevant to the discussion in an interprofessional team meeting unless it specifically impacts the client's access to healthcare resources or affects decision-making regarding their care plan.
The reason for including this information is that difficulty ambulating can impact the client's overall mobility and functional status. It can have implications for their ability to perform activities of daily living, increase the risk of falls, and require additional interventions or resources. By sharing this information with the interprofessional team, appropriate strategies and interventions can be discussed and implemented to address the client's mobility issues.
The client's next dressing change is scheduled in 4 hours: The timing of the client's dressing change may be important for nursing documentation and scheduling purposes. However, it may not be a significant focus of discussion in an interprofessional team meeting unless there are specific concerns or issues related to the dressing change that require collaboration and coordination among the healthcare team.
The client's vital signs are checked every 8 hours: The frequency of vital sign checks is an important aspect of nursing care and monitoring. However, unless there are specific concerns or deviations from normal vital signs that need to be discussed, it may not be the primary information to include in an interprofessional team meeting. The focus of the meeting is typically on broader aspects of the client's condition, care plan, and multidisciplinary interventions.
Correct Answer is A
Explanation
The nurse should allow the family as much time as they want with the client who has just died. This promotes comfort for the family and allows them to say goodbye to their loved one.
a) Using paper tape to hold the client's eyelids open is not appropriate and can be distressing for the family.
b) Placing the client in a supine position is not necessary and may not be comfortable for the client.
c) Avoiding repeating information about the client's death is not helpful. The nurse should provide clear and honest information to the family and answer any questions they may have.
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