When performing dressing changes in an older client, what should the nurse assess for?

Signs of infection

Skin color changes

Decreased pain levels

Changes in blood pressure

Answer and Explanation

The Correct Answer is A

A.   Signs of infection: Older adults may have compromised immune systems and are more susceptible to infections. During dressing changes, the nurse should assess for signs of infection such as increased redness, swelling, warmth, drainage, or foul odor, which could indicate an infection at the wound site.

B.   Skin color changes: While changes in skin color can be indicative of various skin conditions or circulation problems, assessing for signs of infection is more pertinent during dressing changes to prevent and manage complications.
C.   Decreased pain levels: Older adults may have altered pain perception due to age-related changes or comorbidities. However, assessing for signs of infection takes priority during dressing changes to ensure timely intervention if infection is present.

D. Changes in blood pressure: Changes in blood pressure may be relevant in certain clinical contexts but are not specifically related to performing dressing changes in older clients.

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Correct Answer is B

Explanation

A. A 49-year-old who works in food services: While individuals working in food services may be at risk of exposure to influenza, they are not in the highest priority group. Age and underlying health conditions are typically prioritized over occupational risk factors.

B. An 88-year-old who lives in an apartment for senior citizens: Older adults, especially those living in congregate settings like senior citizen apartments, are at higher risk of complications from influenza. Therefore, the 88-year-old should have the highest priority to receive the vaccine.

C. A 26-year-old with three young children: While having young children may increase the risk of exposure to influenza, younger adults without underlying health conditions are generally at lower risk of severe complications compared to older adults.

D. A 15-year-old who plays ice hockey: While participation in activities like ice hockey may increase the risk of exposure to respiratory infections, age and health status are more significant factors in determining priority for influenza vaccination.

A. Place all clients who have manifestations on contact precautions. B. Obtain stool cultures from all clients on the nursing unit. C. Request the providers to initiate antibiotic therapy for every client on the unit. D. Perform hand hygiene with an alcohol-based agent.

Correct Answer is A

Explanation

A. Place all clients who have manifestations on contact precautions: Given the suspicion of Clostridium difficile infection due to the development of watery diarrhea in multiple clients, it is appropriate to place these clients on contact precautions until the diagnosis is confirmed or ruled out. Contact precautions help prevent the spread of the infection by requiring healthcare workers to wear gloves and gowns when entering the room.
B. Obtain stool cultures from all clients on the nursing unit: While obtaining stool cultures may be necessary to confirm the diagnosis of C. difficile infection, implementing contact precautions is more immediate and necessary to prevent transmission.
C. Request the providers to initiate antibiotic therapy for every client on the unit: Initiating antibiotic therapy for every client on the unit without confirmation of C. difficile infection is not appropriate and may contribute to antibiotic resistance.

D. Perform hand hygiene with an alcohol-based agent: Hand hygiene is essential in preventing the spread of infection, but in the case of C. difficile, handwashing with soap and water is recommended over alcohol-based hand sanitizers due to the spore-forming nature of the bacteria.

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When performing dressing changes in an older client, what should the nurse assess for?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

There are limited amounts of influenza vaccine currently available in the clinic. Which individual should the nurse identify as having the highest priority to receive vaccination at this time?

Correct Answer is B

Explanation

A nurse working on a medical-surgical unit suspects that several clients have Clostridium Difficile (C-Diff) when they all develop watery diarrhea. Which of the following actions should the nurse plan to take while waiting for the client's lab results?

Correct Answer is A

Explanation

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