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. A family attorney is the most appropriate professional to contact for more information about advance directives. Attorneys are knowledgeable about the legal aspects of advance directives, including living wills and durable power of attorney for healthcare, and can provide guidance on how to properly complete these documents.
B. A nurse manager may provide general information, but an attorney is more suited to address the legal aspects of advance directives.
C. A hospice nurse focuses on end-of-life care but may not have the expertise to provide comprehensive information about the legal requirements for advance directives.
D. A chaplain can offer spiritual support but is not the best resource for legal information regarding advance directives.

A. Determine if the expected outcomes were realistic. B. Review related professional standards of care. C. Obtain current client data to compare with expected outcomes. D. Modify the nursing interventions to achieve the client's goals.

Correct Answer is C

Explanation

A. Determining if the expected outcomes were realistic is important but comes after comparing the actual client data with the expected outcomes. If the outcomes were unrealistic, it would be identified during this comparison.
B. Reviewing professional standards of care is important for ensuring that care meets quality standards but is not the immediate next step after reviewing the expected outcomes.
C. Obtaining current client data to compare with expected outcomes is the next step to assess whether the client’s condition has improved, worsened, or remained the same. This comparison is crucial for evaluating the effectiveness of the nursing care.
D. Modifying nursing interventions should be done based on the evaluation of client data and outcomes. It is a subsequent step after assessing whether the outcomes have been met.

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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

During the admission process, a client requests more information about advance directives. Which professional should the nurse recommend the client contact?

Correct Answer is A

Explanation

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

Correct Answer is C

Explanation

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