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 A
Explanation
The nurse should administer bronchodilators first for severe wheezing. Bronchodilators work by relaxing the muscles in the airways, which helps to open them up and make it easier to breathe.
Option b is incorrect because beta blockers are not typically used to treat asthma and can actually worsen symptoms in some clients.
Option c is incorrect because inhaled steroids are used to reduce inflammation in the airways over time and are not typically used for immediate relief of severe wheezing.
Option d is incorrect because anti-inflammatory agents are used to reduce inflammation in the airways over time and are not typically used for immediate relief of severe wheezing.
Correct Answer is D
Explanation
When a client with active pulmonary tuberculosis (TB) receives appropriate treatment and their sputum cultures consistently show negative results for Mycobacterium tuberculosis, it indicates that the client is no longer contagious. Negative sputum cultures indicate that the infectious bacteria are no longer present or viable in the respiratory secretions, reducing the risk of transmitting the disease to others.
"You will need an annual TB skin test to see if the infection has returned": While it is important for individuals with a history of TB to undergo periodic screening, such as an annual TB skin test or interferon-gamma release assay (IGRA), to detect latent TB infection or potential reactivation, this response is not specifically related to a client with active pulmonary TB.
"You will take medication to treat your illness for the rest of your life": This response is incorrect because active pulmonary TB is typically treated with a combination of antimicrobial medications for a specific duration, usually ranging from 6 to 9 months. It is not a lifelong treatment.
However, individuals with latent TB infection may require longer-term treatment to prevent the development of active TB disease.
"You can expect the medications to turn your urine a blue-green color": This response is incorrect as medications used to treat TB do not typically cause urine discoloration. Medications such as rifampin can cause various side effects, including orange discoloration of bodily fluids like urine, tears, or sweat, but a blue-green color is not associated with TB medications.
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