A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?

Review the patient's activity orders.

Medicate the patient to alleviate discomfort while ambulating.

Ask for at least two other assistive personnel to come to the room.

Offer the patient a walker.

Answer and Explanation

The Correct Answer is A

A. Before assisting a patient, especially one with mobility concerns, the nurse must verify provider orders to determine any restrictions or special considerations.

B. Administering pain medication before knowing activity restrictions could lead to falls or complications.

C. While assistance may be needed, the first priority is to check the patient's activity orders to determine the safest way to proceed.

D. Providing a walker might help, but the nurse must first confirm whether assistive devices are appropriate for the patient.

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Correct Answer is B

Explanation

A. Skin feeling warm to the touch. This is incorrect because warmth may indicate inflammation, infection, or increased blood flow, but it does not necessarily mean the skin’s integrity is impaired. Skin integrity refers to the structural intactness of the skin.

B. Presence of a wound with partial-thickness skin loss. This is correct because partial-thickness skin loss indicates that the protective barrier of the skin has been compromised. This is a clear sign of impaired skin integrity, which requires appropriate assessment and intervention to promote healing and prevent infection.

C. Dry skin with no visible lesions. This is incorrect because while dry skin may be at risk for breakdown, it does not indicate that the skin is currently impaired. Intact dry skin still maintains its structural integrity.

D. Slight redness of the skin after applying pressure. This is incorrect because transient redness that disappears after pressure relief is not necessarily a sign of skin breakdown. However, if redness persists (non-blanchable erythema), it may indicate a stage 1 pressure injury, which would then suggest potential skin integrity impairment.

A. Nurse's lounge B. Conference area C. Client's bedside D. Outside client's room

Correct Answer is C

Explanation

A. Nurse’s lounge. This is incorrect because the nurse’s lounge is not a private or appropriate setting for a report. It may not be secure, and other personnel who are not directly involved in the client’s care may overhear confidential information, which violates privacy regulations such as HIPAA.

B. Conference area. This is incorrect because, while a conference room provides some privacy, bedside reporting is preferred as it allows for direct patient involvement, immediate clarification, and continuity of care.

C. Client’s bedside. This is correct because bedside reporting enhances communication, ensures the oncoming nurse can visually assess the client, and allows the client to participate in their care. This approach promotes safety and reduces the risk of errors during the handoff.

D. Outside client’s room. This is incorrect because it does not ensure privacy and may not allow for direct verification of client information. Discussing a report outside the room could also expose confidential information to unintended listeners.

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A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following signs is most indicative of impaired skin integrity?

Correct Answer is B

Explanation

A nursing is preparing to give a handoff report to the oncoming nurse. In which of the following areas should the nurse provide report to the oncoming nurse?

Correct Answer is C

Explanation

A nurse administers the prescribed inhaled medication then auscultates the patient's lungs after the medication has finished. In what phase of the nursing process would the nurse's action of auscultating the lungs occur?

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