A nurse is preparing to administer acetaminophen 320 mg PD every 4 hr PRN for pain. The amount available is acetaminophen liquid 160 mg/5 mL. How many mL should the nurse administer per dose? Round to the nearest tenth and label your answer.

A. Swab the drainage from the removed dressing: Collecting a specimen from the dressing may contain contaminants from the external environment or surrounding skin, which can result in inaccurate culture results. The dressing does not reliably reflect the microbial environment of the wound itself.

B. Swab the pool of exudate in the wound bed before irrigating: Swabbing pooled exudate can yield superficial organisms that may not represent the pathogens causing infection. The exudate often contains debris, surface bacteria, and environmental contaminants, making it a less accurate source for culture.

C. Swab the beefy red tissue in the wound bed after irrigating: The proper technique involves first irrigating the wound to remove debris and surface contaminants, then swabbing the viable, granulating tissue. This ensures the culture sample reflects the organisms actively infecting the wound, increasing the accuracy of results for guiding targeted antimicrobial therapy.

D. Swab the skin surrounding the wound prior to wound care: Swabbing the periwound skin will collect normal skin flora rather than organisms in the wound itself. While skin assessment is important for hygiene and preventing infection, it does not provide clinically useful information about the wound infection.

A. Observe for behavioral cues such as facial expressions and body movements: In patients with advanced dementia who cannot verbalize pain, nonverbal indicators such as grimacing, moaning, guarding, restlessness, or changes in posture are reliable signs of discomfort. Systematic observation using validated tools, like the Pain Assessment in Advanced Dementia (PAINAD) scale, allows the nurse to assess pain accurately and guide appropriate interventions.

B. Wait for family members to report if they think the patient is having pain: While family input can provide helpful context regarding the patient’s typical behaviors and responses, relying solely on family reports risks underrecognizing pain episodes and delays timely intervention. Direct observation by the nurse is essential for continuous assessment.

C. Depend only on vital sign changes to determine the presence of pain: Although pain can cause increases in heart rate, blood pressure, or respiratory rate, these changes are nonspecific and can result from multiple causes. Vital signs alone are insufficient to identify pain, especially in older adults who may have blunted physiologic responses.

D. Assume the patient is pain-free unless they verbally express pain: Assuming absence of pain without verbal confirmation risks undertreatment and patient suffering. Many patients with advanced dementia cannot communicate verbally, so proactive observation and assessment are required to identify and manage pain effectively.