An older adult client is admitted to the medical unit following a fall at home. While undressing the client, the nurse observes that the client is wearing an adult diaper and skin breakdown is obvious over the sacral area. Which action should the nurse implement first?

Apply a barrier ointment to intact areas that may be exposed to moisture.

Determine the size and depth of skin breakdown over the sacral area.

Complete a functional assessment of the client's self-care abilities.

Establish a toileting schedule to decrease episodes of incontinence.

Answer and Explanation

The Correct Answer is B

A. While applying a barrier ointment is important for preventing further skin breakdown, it does not address the immediate need to assess the severity of existing damage.
B. Determining the size and depth of skin breakdown is crucial for assessing the severity of the pressure injury and planning appropriate treatment. Accurate assessment helps in selecting the right interventions and monitoring the progression of the wound.
C. Completing a functional assessment of the client's self-care abilities is important for overall care planning but should follow the initial assessment of the skin breakdown to ensure immediate needs are addressed.
D. Establishing a toileting schedule is a preventive measure for future incontinence but does not address the current skin breakdown that needs immediate assessment and treatment.

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Correct Answer is B

Explanation

A. Leaving the dressing off could increase the risk of infection and delay wound healing. It is important to follow established wound care protocols and consult the healthcare provider if necessary.
B. Applying a hydrocolloidal gel dressing is appropriate for a stage 3 pressure ulcer with significant granulation tissue as it helps maintain a moist wound environment conducive to healing and protects the wound from external contaminants.
C. Replacing gauze with a transparent dressing might not provide adequate moisture control for a granulating wound and could potentially cause damage when removed.
D. Increasing the frequency of dressing changes may not be necessary and could potentially disrupt the healing process. It is important to balance between protecting the wound and allowing it to heal properly.

A. Raise the four side rails on the bed. B. Close the client's room door. C. Orient the client to the surroundings. D. Secure a bed alarm on the mattress. E. Escort the client back to her room.

Correct Answer is ["C","D","E"]

Explanation

A. Raising the four side rails on the bed can be considered a form of restraint and might increase the risk of injury if the client attempts to climb over them. It is not recommended unless necessary and in accordance with facility policies.
B. Closing the client's room door could increase the client's confusion and sense of isolation, making it harder for the staff to monitor the client’s safety.
C. Orienting the client to the surroundings is essential in reducing confusion and preventing further wandering. It helps the client feel more secure and less disoriented.
D. Securing a bed alarm on the mattress is a proactive safety measure that can alert the staff if the client attempts to leave the bed again, thus preventing potential harm.
E. Escorting the client back to her room ensures immediate safety and provides an opportunity to assess the client's condition and needs in a controlled environment.

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An older adult client is admitted to the medical unit following a fall at home. While undressing the client, the nurse observes that the client is wearing an adult diaper and skin breakdown is obvious over the sacral area. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

Correct Answer is B

Explanation

The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? (Select all that apply)

Correct Answer is ["C","D","E"]

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

The nurse is preparing a client placed on droplet precautions for transport from the client's room to another department. The client wears eyeglasses and refuses to remove them while being transported. Which action should the nurse take?

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The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?