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 A

Explanation

A. Swelling, tenderness, and purulent drainage around the wound are classic signs of a wound infection. Swelling and tenderness indicate inflammation, while purulent drainage (pus) suggests the presence of infection.
B. Urticaria and itching around the wound are more indicative of an allergic reaction or hypersensitivity rather than a wound infection.
C. Serosanguineous drainage (clear to blood-tinged fluid) is a normal finding in the early stages of wound healing and does not necessarily indicate infection.
D. Brown crusting over the wound may indicate the formation of an eschar, which can occur in wounds undergoing healing, particularly in wounds with necrotic tissue. It is not necessarily indicative of infection unless accompanied by other signs such as erythema, warmth, or purulent drainage.

A. Bullae B. Nodules C. Papules D. Macules

Correct Answer is B

Explanation

A. Bullae: Bullae are fluid-filled lesions larger than 0.5 cm in diameter.
B. Nodules: Nodules are elevated, solid lesions deeper and firmer than papules, typically larger than 0.5 cm in diameter.
C. Papules: Papules are elevated, solid lesions smaller than 0.5 cm in diameter.
D. Macules: Macules are flat, colored lesions that are smaller than 1 cm in diameter.

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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

A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?

Correct Answer is A

Explanation

A nurse in a provider's office is collecting data from a client who has skin lesions. The nurse notes that the lesions are 2.5 cm in size, elevated, solid, and deep. The nurse should document the findings as which of the following skin lesions?

Correct Answer is B

Explanation

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