A nurse is assisting with discharge planning for an older adult client who will require dressing changes for a healing pressure ulcer twice daily at home. Which of the following services should the nurse recommend?

Adult day care

Long-term care

Wound care

Palliative care

Answer and Explanation

The Correct Answer is C

A. Adult day care is a service that provides care and supervision to adults who need assistance during the day, often due to physical or cognitive impairments. However, it may not be specifically geared toward providing wound care services.

B. Long-term care typically involves comprehensive, ongoing assistance with activities of daily living for individuals who have chronic illnesses or disabilities. While wound care may be part of long-term care, it's not the primary focus, and it is often provided in various settings, including home care.

C. Wound care is the most appropriate recommendation for an older adult client requiring dressing changes for a healing pressure ulcer. This service may include home health nursing visits to perform the necessary wound care, monitor healing progress, and provide education to the client and their caregivers.

D. Palliative care is focused on providing relief from the symptoms and stress of a serious illness, and it can be appropriate for clients with chronic conditions. However, in this scenario, the primary need is for wound care rather than palliative care.

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Correct Answer is A

Explanation

A. Use of the Braden scale for clients who are immobile.

The Braden Scale is a widely used tool for assessing the risk of pressure ulcer development. It includes various factors such as sensory perception, moisture, activity, mobility, nutrition, and friction/shear. For clients who are immobile, the Braden Scale helps identify their risk for skin breakdown and guides the implementation of preventive measures.

B. Daily weighing of clients who have heart failure:

Daily weighing of clients with heart failure is important for monitoring fluid status, but it is not specifically focused on decreasing the risk of skin breakdown. Skin breakdown is more closely related to factors such as immobility, pressure, and friction.

C. Documentation of PAINAD scale for clients who have dementia:

The PAINAD scale is used to assess pain in clients with advanced dementia. While managing pain is important for overall well-being, it is not a direct measure for decreasing the risk of skin breakdown. Skin breakdown prevention is more related to factors like pressure relief and moisture management.

D. Implementation of incentive spirometry for clients who are postoperative:

Incentive spirometry is primarily aimed at promoting lung expansion and preventing respiratory complications after surgery. While postoperative care is essential, it does not directly address the risk of skin breakdown. Skin breakdown prevention involves interventions related to pressure relief, repositioning, and skin care.

Correct Answer is ["4"]

Explanation

To calculate the volume (mL) that the nurse should administer per dose, you can use the following formula:

Volume (mL) = Dose (units)/Concentration (units/mL)

In this case:

Volume = 400,000 units/100,000 units/mL
Volume=4mL

Therefore, the nurse should administer 4 mL of Mycostatin oral suspension per dose.

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A nurse is assisting with discharge planning for an older adult client who will require dressing changes for a healing pressure ulcer twice daily at home. Which of the following services should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing documentation on a group of clients as part of a quality improvement initiative. Which of the following actions should the nurse document as decreasing the risk for skin breakdown?

Correct Answer is A

Explanation

A nurse is preparing to administer mycostatin 400,000 units PO every 6 hr. Available is mycostatin oral suspension 100,000 units/mL. How many ml should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["4"]

Explanation

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