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. Avoiding use of a urinary catheter B. Applying absorbent briefs C. Restricting Fluids D. Toileting patient every 4 hours

Correct Answer is B

Explanation

A. Avoiding use of a urinary catheter: While avoiding unnecessary urinary catheterization is important to prevent healthcare-associated urinary tract infections, this action may not be directly applicable to an incontinent patient who requires interventions to manage incontinence.
B. Applying absorbent briefs: Using absorbent briefs helps contain urine and feces, reducing the risk of skin breakdown and contamination of the environment.
C. Restricting Fluids: Restricting fluids may lead to dehydration and is not a recommended approach for preventing healthcare-associated infections in incontinent patients.
D. Toileting patient every 4 hours: Toileting frequency should be individualized based on the patient's needs and not restricted to a specific time interval. Additionally, simply toileting the patient may not be sufficient to prevent healthcare-associated infections if proper hygiene practices are not followed.

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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

Which of the following actions can the nurse take to help prevent a health care-associated infection in an incontinent patient?

Correct Answer is B

Explanation

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