A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Choice A reason:

Urinary hesitancy, while concerning, is not typically an immediate threat to the client’s health. It can indicate underlying issues such as benign prostatic hyperplasia (BPH) or urinary tract infections, which require medical attention but are generally not life-threatening. Addressing urinary hesitancy is important, but it does not take precedence over more acute conditions.

Choice B reason:

Swollen gums can be a sign of poor oral hygiene, gingivitis, or other dental issues. While important to address, swollen gums are not usually an immediate threat to the client’s overall health. Dental issues can lead to complications if left untreated, but they do not typically require urgent intervention.

Choice C reason:

Dysphagia, or difficulty swallowing, is a priority because it can lead to serious complications such as aspiration pneumonia, malnutrition, and dehydration. Aspiration pneumonia occurs when food or liquid enters the lungs, leading to infection. Dysphagia can also cause significant discomfort and impact the client’s ability to eat and drink adequately, making it a critical issue to address promptly.

Choice D reason:

Pruritus, or itching, can be a symptom of various conditions, including allergies, skin disorders, or systemic diseases such as liver or kidney problems. While pruritus can be very uncomfortable and impact the client’s quality of life, it is not typically an immediate threat to health. It requires assessment and management but is not as urgent as dysphagia.

Choice A reason:

Administering medication with an oral syringe is a recommended practice for giving liquid medication to infants. An oral syringe allows for accurate measurement and controlled delivery of the medication, reducing the risk of choking and ensuring the infant receives the correct dose. Therefore, this statement does not indicate a need for further instruction.

Choice B reason:

Inserting the medication in the infant’s buccal cavity (the space between the gums and the cheek) is also a recommended technique. This method helps to prevent the infant from spitting out the medication and ensures better absorption. Hence, this statement does not indicate a need for further instruction.

Choice C reason:

Allowing the infant to swallow some of the medication before administering more is a safe and effective way to give medication. This approach helps to prevent choking and ensures that the infant can handle the amount of medication being given. Therefore, this statement does not indicate a need for further instruction.

Choice D reason:

Positioning the infant in a supine position (lying flat on their back) is not recommended when administering oral medication. This position increases the risk of aspiration, where the medication could enter the airway instead of the esophagus. The correct position is to hold the infant in an upright or semi-upright position to ensure safe swallowing and reduce the risk of choking or aspiration. Therefore, this statement indicates a need for further instruction.