When performing dressing changes in an older client, what should the nurse assess for?
Signs of infection
Skin color changes
Decreased pain levels
Changes in blood pressure
The Correct Answer is A
A. Signs of infection: Older adults may have compromised immune systems and are more susceptible to infections. During dressing changes, the nurse should assess for signs of infection such as increased redness, swelling, warmth, drainage, or foul odor, which could indicate an infection at the wound site.
B. Skin color changes: While changes in skin color can be indicative of various skin conditions or circulation problems, assessing for signs of infection is more pertinent during dressing changes to prevent and manage complications.
C. Decreased pain levels: Older adults may have altered pain perception due to age-related changes or comorbidities. However, assessing for signs of infection takes priority during dressing changes to ensure timely intervention if infection is present.
D. Changes in blood pressure: Changes in blood pressure may be relevant in certain clinical contexts but are not specifically related to performing dressing changes in older clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. To relieve itching or discomfort: Skin biopsies are not typically performed to relieve itching or discomfort. Other treatments, such as topical medications or systemic therapies, may be used for symptomatic relief.
B. To improve the appearance of the skin: Skin biopsies are not performed for cosmetic purposes. They are diagnostic procedures used to obtain tissue samples for examination under a microscope to diagnose or rule out various skin conditions.
C. To remove a suspicious lesion: Skin biopsies are commonly performed to remove suspicious lesions, such as moles, growths, or areas of abnormal skin, for further evaluation and diagnosis.
This helps determine if the lesion is benign or malignant and guides subsequent treatment decisions.
D. To treat a skin infection: Skin biopsies are not performed as a primary treatment for skin infections. Biopsies are diagnostic procedures used to obtain tissue samples for analysis and are not typically indicated for treating infections.
Correct Answer is B
Explanation
A. Implement neutropenia isolation: Neutropenia isolation is not applicable for a client with C. diff infection. Neutropenia isolation is used for clients with low neutrophil counts to protect them from exposure to pathogens due to their compromised immune system.
B. Disinfect equipment with bleach solution: Clostridium difficile spores are resistant to many disinfectants, but they can be effectively killed by bleach solutions (sodium hypochlorite).
Disinfecting equipment with bleach solution helps prevent the spread of C. diff infection.
C. Monitor the client for manifestations of fluid overload: Manifestations of fluid overload, such as edema or shortness of breath, are not typically associated with C. diff infection. Monitoring for fluid overload is important in other clinical contexts, such as heart failure.
D. Use alcohol hand sanitizer following client care: Alcohol-based hand sanitizers are not effective against C. diff spores. Hand hygiene should be performed with soap and water, as alcohol-based sanitizers are not effective against C. diff spores.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.