A nurse is caring for an older adult client with dementia.
A nurse is caring for an older adult client with dementia. What preventative
measures should the nurse institute to reduce the risk of falls?
o Communicate identified risk to the healthcare provider,
o perform fall risk assessment, place the client in a room close to the
nursing station, provide nonskid foot wear, remove clutter from room
and floor, provide adequate lighting and keep bed in the lowest position
A nurse is providing discharge education to a client regarding home wound care.
What manifestations of wound infection should the nurse include in this
education?
o The nurse should include pain, redness, purulent drainage, fever, chills,
edema around the wound, increased respiratory rate, increased heart rate
List at least five (5) priority considerations when performing a sterile dressing
change.
o Perform hand hygiene
o Check the sterile package and the surrounding to be used
o Utilize a clean environment and keep sterile field above the waist area
o Position field on a clean surface before donning glove
o Touch sterile object with sterile glove and keep sterile filed within sight
o Once glove is applied 1 inch of sterile filed is considered not sterile
A nurse is caring for a client receiving oxygen therapy. What is the expected
reference range when obtaining oxygen saturation level? Identify four (4)
reasons the reference range may be lower.
o Patient skin is dark
o Poor peripheral blood flow
o Nail polish
o low hemoglobin levels
List five (5) expected assessment findings for the older adult due to the physical
changes during aging.
o Decreased skin turgor and subcutaneous fat
o Thickening of finger nail and toenail
o Decreased cardiac output and peripheral circulation
o Decreased reaction time, smell and sensation
o Increased blood pressure
The nurse has been assigned to a post-abdominal surgery client who has also
been diagnosed with dementia. The family is concerned about pain control for
the client because the client is confused. What should the nurse include in their
teaching to the family about the pain control plan for this client?
o Pt vital signs indicates pain and are assessed frequently
o Explain trend in behavior changes of patient with dementia when they are in
This study source was downloaded by 100000832558064 from CourseHero.com on 04-03-2022 10:28:10 GMT -05:00
https://www.coursehero.com/file/35057612/A-nurse-is-caring-for-an-older-adult-client-with-dementiadocx/
, A nurse is caring for an older adult client with dementia.
pain
o Teach pre-medication client before activity and before expected pain
A client reports difficulty falling asleep. What are nursing interventions to promote
sleep?
This study source was downloaded by 100000832558064 from CourseHero.com on 04-03-2022 10:28:10 GMT -05:00
https://www.coursehero.com/file/35057612/A-nurse-is-caring-for-an-older-adult-client-with-dementiadocx/
A nurse is caring for an older adult client with dementia. What preventative
measures should the nurse institute to reduce the risk of falls?
o Communicate identified risk to the healthcare provider,
o perform fall risk assessment, place the client in a room close to the
nursing station, provide nonskid foot wear, remove clutter from room
and floor, provide adequate lighting and keep bed in the lowest position
A nurse is providing discharge education to a client regarding home wound care.
What manifestations of wound infection should the nurse include in this
education?
o The nurse should include pain, redness, purulent drainage, fever, chills,
edema around the wound, increased respiratory rate, increased heart rate
List at least five (5) priority considerations when performing a sterile dressing
change.
o Perform hand hygiene
o Check the sterile package and the surrounding to be used
o Utilize a clean environment and keep sterile field above the waist area
o Position field on a clean surface before donning glove
o Touch sterile object with sterile glove and keep sterile filed within sight
o Once glove is applied 1 inch of sterile filed is considered not sterile
A nurse is caring for a client receiving oxygen therapy. What is the expected
reference range when obtaining oxygen saturation level? Identify four (4)
reasons the reference range may be lower.
o Patient skin is dark
o Poor peripheral blood flow
o Nail polish
o low hemoglobin levels
List five (5) expected assessment findings for the older adult due to the physical
changes during aging.
o Decreased skin turgor and subcutaneous fat
o Thickening of finger nail and toenail
o Decreased cardiac output and peripheral circulation
o Decreased reaction time, smell and sensation
o Increased blood pressure
The nurse has been assigned to a post-abdominal surgery client who has also
been diagnosed with dementia. The family is concerned about pain control for
the client because the client is confused. What should the nurse include in their
teaching to the family about the pain control plan for this client?
o Pt vital signs indicates pain and are assessed frequently
o Explain trend in behavior changes of patient with dementia when they are in
This study source was downloaded by 100000832558064 from CourseHero.com on 04-03-2022 10:28:10 GMT -05:00
https://www.coursehero.com/file/35057612/A-nurse-is-caring-for-an-older-adult-client-with-dementiadocx/
, A nurse is caring for an older adult client with dementia.
pain
o Teach pre-medication client before activity and before expected pain
A client reports difficulty falling asleep. What are nursing interventions to promote
sleep?
This study source was downloaded by 100000832558064 from CourseHero.com on 04-03-2022 10:28:10 GMT -05:00
https://www.coursehero.com/file/35057612/A-nurse-is-caring-for-an-older-adult-client-with-dementiadocx/
