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A nurse is delegating care of an older client with a high risk for skin breakdown to unlicensed assistive personnel (UAP). Which statements by the nurse are appropriate? (Select all that apply.)
- A. Assess the client's skin daily and report any redness
- B. Order a special mattress if you notice skin breakdown
- C. Keep the client's skin dry and free of moisture
- D. Turn the client every 2 hours to prevent pressure ulcers
- E. Reassess the Braden Scale results every shift
Correct Answer: C,D,E
Rationale: The nurse's aide or UAP can assist in keeping the client's skin dry, order a special mattress on direction of the RN, and turn the client on a schedule. Assessing the skin is a nursing responsibility, although the aide should be instructed to report any redness noticed. Reassessing the Braden Scale results is the RN's responsibility, as the RN is the one who performs the main assessment.
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A nurse is caring for an older adult who reports not eating well. What actions by the nurse are most appropriate? (Select all that apply.)
- A. Ask about transportation to buy food
- B. Inquire about access to dentures
- C. Encourage the client to continue the current exercise plan
- D. Have the client complete a 3-day diet recall diary
- E. Teach the client about proper nutrition in the older population
Correct Answer: A,B,D
Rationale: Assessment is the first step of the nursing process and should be completed prior to intervening. Asking about transportation, dentures, and normal food patterns would be part of an appropriate assessment for the client. There is no information in the question about the older adult needing to lose weight, so encouraging them to continue the current exercise plan is premature and may not be appropriate. Teaching about proper nutrition is a good idea, but teaching needs to be tailored to the client's needs, which the nurse does not yet know.
A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the client demonstrates a need for further review?
- A. Barley soup
- B. Black beans
- C. White rice
- D. Whole wheat bread
Correct Answer: C
Rationale: Older adults need 25 to 50 grams of fiber a day. White rice is low in fiber. Foods high in fiber include barley, beans, and whole wheat products.
An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the nurse would be most helpful for preventing falls in this client?
- A. Keep the light on in the bathroom at night
- B. Order a wheelchair for the client
- C. Put the client on a toileting schedule
- D. Use side rails to keep the client in bed
Correct Answer: A
Rationale: Although this older adult is independent and ambulatory, being hospitalized can create confusion. Getting up in a dark, unfamiliar environment can contribute to falls. Keeping the light on in the bathroom at night helps ensure the client can see their surroundings, reducing the risk of falls.
An older adult client takes medication three times a day and becomes confused about which medication should be taken at which time. The client refuses to use a pill sorter with slots for different times, saying 'Those are for old people.' What action by the nurse would be most helpful?
- A. Arrange medications by time in a drawer
- B. Encourage the client to use easy-open tops
- C. Place color-coded stickers on the bottle caps
- D. Write a list of which medications to take when
Correct Answer: C
Rationale: Color-coded stickers are a fast, easy-to-remember system. One color is for morning meds, one for evening meds, and the third color is for nighttime meds. Arranging medications by time in a drawer might be helpful if the person doesn't accidentally put them back in the wrong spot. Easy-open tops are not related. Writing a list is helpful, but it may be misplaced. With stickers on the medication bottles themselves, the reminder is always with the medication.
A nurse caring for an older client on a medical-surgical unit notices the client reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment should the nurse perform first?
- A. Auscultate bowel sounds
- B. Palpate the abdomen
- C. Review the client's medication list
- D. Assess dietary fiber intake
Correct Answer: D
Rationale: Assessing dietary fiber intake is critical as the client's preference for softer, low-fiber foods like rice, bread, and puddings may contribute to constipation. This assessment should be prioritized to identify potential causes before proceeding to other assessments like auscultating bowel sounds or palpating the abdomen.