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 B

Explanation

A. The use of "2.0 mg" is incorrect because trailing zeros can lead to dosage errors. The correct documentation should avoid trailing zeros to prevent misinterpretation.
B. "Morphine 2 mg IV every 4 hr PRN for severe pain" is the correct format. It uses the full name of the drug, avoids abbreviations that could be confused, and follows best practices for documenting as-needed (PRN) medications.
C. Using "MS" instead of "morphine" is not recommended because "MS" can be confused with magnesium sulfate or other medications. The full drug name should always be used.
D. Similar to option A, the use of "2.0 mg" includes a trailing zero, which should be avoided to reduce the risk of errors in medication administration.

A. Tennis shoes with velcro. B. Rubber-soled slippers. C. Slip-on rubber shower shoes. D. Leather-soled loafers.

Correct Answer is A

Explanation

A. Tennis shoes with velcro are recommended because they provide good support, traction, and stability, which are crucial for a client with residual weakness after a stroke. The velcro allows for easy adjustment and ensures the shoes are secure, reducing the risk of tripping or falling.
B. Rubber-soled slippers, while comfortable, may not offer the necessary support or secure fit needed for safe ambulation.
C. Slip-on rubber shower shoes are not suitable for ambulation outside of the shower area due to their lack of support and potential to slip off.
D. Leather-soled loafers can be slippery and do not provide the traction needed for safe walking, especially on smooth surfaces.

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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

The healthcare provider gives a verbal prescription for 2 mg of intravenous morphine to be given to a client every 4 hours as needed for severe pain. How should the nurse document the prescription?

Correct Answer is B

Explanation

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

Correct Answer is A

Explanation

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