A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take?

Press the skin over the client's ankle bone.

Observe for non blanching, pinpoint-size, red or purple spots on the skin of the abdomen.

Lightly palpate the skin using the fingertips.

Grasp a fold of skin on the client's forearm or near the sternum.

Answer and Explanation

The Correct Answer is D

A. Press the skin over the client's ankle bone. Skin over the bony prominences is not ideal for assessing turgor, as it may not accurately reflect dehydration.

B. Observe for non-blanching, pinpoint-size, red or purple spots on the skin of the abdomen. This describes petechiae, which is a sign of bleeding disorders, not hydration status.

C. Lightly palpate the skin using the fingertips. Palpation does not assess elasticity.

D. Grasp a fold of skin on the client's forearm or near the sternum. The best way to check for dehydration is by pinching the skin on the sternum or forearm and observing how quickly it returns to normal.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Nasal flaring present. Nasal flaring is a separate sign of respiratory distress, but it does not describe retractions.

B. Suprasternal retractions present. Suprasternal retractions occur above the sternum, not between the ribs.

C. Intercostal retractions present. Intercostal retractions occur between the ribs and indicate difficulty breathing due to increased respiratory effort.

D. Subcostal retractions present. Subcostal retractions occur below the ribcage, not between the ribs.

A. A reddened area over the sacrum B. Difficulty moving the upper extremities C. Stiffness in the lower extremities D. Difficulty hearing some types of sounds

Correct Answer is A

Explanation

A. A reddened area over the sacrum. This is an early sign of a pressure ulcer, a common complication of immobility in bed-bound clients.

B. Difficulty moving the upper extremities. While weakness may occur after a stroke, this is not a complication of immobility but rather a direct effect of neurological damage.

C. Stiffness in the lower extremities. Some stiffness may occur, but contractures or deep vein thrombosis (DVT) would be more concerning immobility-related complications.

D. Difficulty hearing some types of sounds. Hearing loss is not a complication of immobility.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A child is being evaluated for increased work of breathing. While inspecting the child's chest, the nurse notes pulling in or sucking in of the skin between the child's ribs. How might the nurse accurately document this finding?

Correct Answer is C

Explanation

An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

Correct Answer is A

Explanation

The nurse is planning to auscultate heart sounds. The history and physical indicates a history of Aortic Valve dysfunction. Where would the nurse auscultate to assess the Aortic Valve?

A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicate adaptive coping? (Select all that apply.)

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

A nurse is collecting data from a client who is experiencing stress. Which of the following findings should indicate to the nurse ineffective coping?

A nurse is observing a newly licensed nurse perform focused data collection on a client who has developed a skin condition. Which of the following questions by the newly licensed nurse requires intervention by the nurse?

A nurse is collecting data from a client who has a urine output of 250 mL in a 24-hr period. Which of the following terms should the nurse use to document this finding in the electronic record?

A nurse is assisting in preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following alterations is appropriate for the nurse to include?

A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply.)