A nurse is caring for an older adult client who reports dry, itchy skin. Which of the following actions should the nurse take?

Encourage the client to bathe frequently.

Apply powder to the client's skin.

Add moisturizing oil to the client's bath water.

Place a humidifier in the client's room.

Answer and Explanation

The Correct Answer is D

Dry, itchy skin is a common concern in older adults, especially during the winter months or in dry environments. Increasing the humidity in the client's environment can help alleviate dryness and itching. Placing a humidifier in the client's room will add moisture to the air and help prevent excessive drying of the skin. It is important to ensure that the humidifier is clean and well-maintained to avoid the growth of bacteria or mould.

Encouraging the client to bathe frequently may further dry out the skin, so it is not recommended. Similarly, applying powder to the skin may exacerbate dryness and should be avoided. Adding moisturizing oil to the bath water may provide temporary relief, but a humidifier will have a more consistent and long-lasting effect on the client's environment.

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Correct Answer is B

Explanation

Choice A Reason:

Prolonged PT/INR (prothrombin time/international normalized ratio) is not typically seen in pancreatitis. It may be indicative of liver dysfunction or issues with blood clotting.

Choice B Reason:

Elevated lipase levels are commonly seen in clients with pancreatitis. Lipase is an enzyme produced by the pancreas, and when there is inflammation or damage to the pancreas, such as in pancreatitis, it can lead to the release of lipase into the bloodstream. Therefore, an elevated lipase level is a typical laboratory finding in clients with pancreatitis.

Choice C Reason:

Elevated ammonia levels are not typically associated with pancreatitis. Elevated ammonia levels may be seen in clients with liver disease or other metabolic disorders.

Choice D Reason:

Decreased albumin levels are not typically associated with pancreatitis. Decreased albumin levels may be seen in clients with liver disease or malnutrition, but it is not a specific marker for pancreatitis.

A. Raises all four side-rails on the client's bed B. Assists the client to the bathroom every 2 hr C. Clears furniture from the path leading to the bathroom D. Locks the wheels on the client's bed

Correct Answer is A

Explanation

Choice A Reason:

Raises all four side-rails on the client's bed .The nurse should intervene when the assistive personnel (AP) raises all four side-rails on the client's bed. Using all four side-rails on the bed is considered a restraint, and its use should be avoided unless there is a specific clinical indication and an order from the healthcare provider. Restraints should only be used when less restrictive alternatives have been attempted and are not successful in preventing the client from falling.

Choice B Reason:

Assisting the client to the bathroom every 2 hours is a proactive measure to help the client maintain their continence and reduce the risk of falls associated with trying to get to the bathroom independently.

Choice C Reason:

Clearing furniture from the path leading to the bathroom helps create a safe and unobstructed environment for the client to navigate.

Choice D Reason:

Locking the wheels on the client's bed is an appropriate safety measure to prevent the bed from moving while the client is getting in or out.

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A nurse is caring for an older adult client who reports dry, itchy skin. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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