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 A

Explanation

A. The first priority is to notify the information services department to address the technical issue with the computer system. This ensures that the problem is being handled and allows the nurse to focus on immediate patient care needs.
B. Printing the EMR from the backup server is not possible until the issue with the computer system is resolved. Immediate reporting to IT is necessary to address the technical problem first.
C. Identifying information as a late entry is premature and not the immediate priority. Ensuring the functionality of the electronic system is crucial before making manual records.
D. Waiting for the system to reboot does not address the immediate need for technical support and may delay patient care.

A. Muscle strength and tone. B. Presence of rebound phenomenon. C. Limitations to range of motion. D. Degree of neurosensory impairment.

Correct Answer is D

Explanation

A. Muscle strength and tone are important assessments but are not directly related to the safe use of a heating pad.
B. The rebound phenomenon, where the effects of heat application reverse after prolonged exposure, is a consideration, but not as crucial as assessing for neurosensory impairment.
C. Limitations to range of motion may be important for mobility assessments but are less relevant to the safe application of heat therapy.
D. Assessing the degree of neurosensory impairment is most important before applying a heating pad. If the client has impaired sensation, they may not be able to detect if the heating pad is too hot, which could lead to burns or other injuries.

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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

While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?

Correct Answer is A

Explanation

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Correct Answer is D

Explanation

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