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 C

Explanation

A. Elevating the area and applying light pressure is not appropriate for a small raised area from an intradermal injection, which is usually a normal reaction and not an indication for elevation or pressure.
B. Applying a cold pack is unnecessary and may not be appropriate unless there is significant discomfort or an allergic reaction, which is not suggested by the description of a small, raised area.
C. Documenting the site where the medication was given is important for record-keeping and monitoring the reaction to the intradermal test. This helps in assessing normal reactions versus abnormal ones later.
D. Notifying the healthcare provider of an allergic response should be done if the reaction is severe or unexpected, but a small, round raised area is typically a normal response to an intradermal injection.

A. Keep the medication and see if the client will want to take it later. B. Credit the medication back and put it in the client's medication box. C. Explain that since the medication is a controlled substance it must be taken. D. Have another nurse watch the disposal of the medication into the disposal container.

Correct Answer is D

Explanation

A. The medication should not be kept or stored once it has been removed from its original packaging, especially if it’s not administered. Proper disposal or return to the pharmacy is required.
B. The medication should not be put back in the client’s medication box due to safety and contamination concerns.
C. While controlled substances need careful management, the client’s refusal must be respected, and the medication must be disposed of properly if not administered.
D. Having another nurse witness the disposal of the medication ensures that it is done according to protocols and provides accountability. This practice helps maintain the integrity and safety of medication handling.

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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

A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

Correct Answer is C

Explanation

The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?

Correct Answer is D

Explanation

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