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. Droplet: Droplet precautions are used for diseases transmitted by large droplets expelled during coughing, sneezing, or talking, such as influenza or pertussis.
B. Contact: Contact precautions are used for diseases transmitted by direct contact with the
patient or indirect contact with contaminated objects or surfaces, such as MRSA or Clostridium difficile (C. diff).
C. Protective: Protective precautions are not a standard category of transmission-based precautions. It is not applicable in this context.
D. Airborne: Airborne precautions are used for diseases transmitted by small particles suspended in the air, such as tuberculosis or measles.

A. Treatment is to continue for 7 days. B. The appearance of the area is to be documented. C. The procedure is performed with clean technique. D. Room temperature normal saline is prescribed.

Correct Answer is D

Explanation

A. Treatment is to continue for 7 days: This aspect of the prescription is clear and does not require clarification.
B. The appearance of the area is to be documented: Documenting the appearance of the area is a standard nursing practice and does not require clarification from the physician.
C. The procedure is performed with clean technique: The use of clean technique for the procedure is appropriate for the management of a pressure injury and does not require clarification.
D. Room temperature normal saline is prescribed: This aspect of the prescription may require clarification as the nurse needs to ensure that the prescribed solution matches the intended
treatment. Clarification may be necessary if there are specific preferences or considerations regarding the type or temperature of the saline solution to be used.

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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 assisting with the admission of a client who has a new diagnosis of Methicillin- Resistant Staphylococcus aureus (MRSA). The nurse should plan to place the client in which of the following types of transmission-based precautions?

Correct Answer is B

Explanation

A patient is admitted for treatment for a severe ulcerated pressure injury exhibiting signs of infection. The HCP prescribes open wet dressings to be applied every 6 hours for a period of 30 minutes for one week. For which part of the prescription does the nurse clarify with the physician?

Correct Answer is D

Explanation

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