A hospitalized older adult has been assessed at high risk for ...

[DyllonKazuo]

A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does the registered nurse (RN) delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
 
  a. Assess skin redness when turning.
  b. Document Braden Scale results.
  c. Keep the client's skin dry.
  d. Obtain a pressure-relieving mattress.
  e. Turn the client every 2 hours.

Question 2

A visiting nurse is in the home of an older adult and notes a 7-pound weight loss since last month's visit. What actions should the nurse perform first? (Select all that apply.)
 
  a. Assess the client's ability to drive or transportation alternatives.
  b. Determine if the client has dentures that fit appropriately.
  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.

[abctaiwan]

Answer to Question 1

ANS: C, D, E
The nurses' 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 directed to report any redness noticed. Documenting the Braden Scale results is the RN's responsibility as the RN is the one who performs that assessment.

Answer to Question 2

ANS: A, B, D
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 him or her to continue the current exercise regimen 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.