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 C

Explanation

A. While it is important to address unprofessional behavior, directly warning the colleague may not be sufficient to address the breach of security protocols effectively.
B. Discussing the action at a staff meeting may not address the immediate issue and could lead to general discussions rather than specific corrective actions.
C. Communicating the observation to the charge nurse is appropriate because it ensures that the issue is reported to a person who can take immediate action to address the breach of EHR security and prevent further unauthorized access.
D. Filing a detailed incident report may be necessary, but first, informing the charge nurse is crucial for immediate action and to address the issue promptly. The charge nurse can then guide the next steps, including filing a report if necessary.

A. Ask the UAP to offer a backrub to the client. B. Reassess the client and the level of pain. C. Tell the client the medication needs more time to work. D. Encourage the client to focus on taking deep breaths.

Correct Answer is B

Explanation

A. Asking a UAP to offer a backrub is not appropriate if the pain assessment indicates that the current pain management strategy is insufficient. The nurse needs to reassess the pain to determine the effectiveness of the medication and whether additional interventions are needed.
B. Reassessing the client and the level of pain is essential to evaluate the effectiveness of the morphine sulfate administered and to guide further pain management decisions. This step is crucial for understanding the client's current pain status and determining the next steps in pain management.
C. Telling the client that the medication needs more time to work does not address the client's immediate concern or pain relief. Reassessing pain and potentially adjusting the treatment plan is more appropriate.
D. Encouraging deep breathing may help with pain management but does not address the need for further assessment of the pain level or potential adjustment in medication. Reassessing pain is the priority.

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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 observes a colleague sharing computer credentials with a colleague who is struggling with access to the electronic health record (EHR). Which action should the nurse take?

Correct Answer is C

Explanation

A client is requesting medicine for pain 30 minutes after receiving morphine sulfate 5 mg intravenously. Which intervention should the nurse implement next?

Correct Answer is B

Explanation

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