After repositioning an older adult client from the right to the left side, the practical nurse (PN) observes a reddened area on the client's right hip over the area of the greater trochanter. Which action should the PN take?
Offer the client fluids and a high protein snack.
Compare range of motion of the client's legs.
Determine the ability of the tissue to blanch.
Assess elasticity of the surrounding tissue.
The Correct Answer is C
Rationale:
A. Offer the client fluids and a high protein snack: Adequate hydration and nutrition are important for skin integrity and wound prevention, but these measures do not immediately identify whether the reddened area represents a developing pressure injury. They are supportive interventions rather than diagnostic actions.
B. Compare range of motion of the client's legs: Assessing joint mobility is important for overall musculoskeletal health and preventing contractures, but it does not provide direct information about skin perfusion or the severity of a reddened area caused by pressure.
C. Determine the ability of the tissue to blanch: Assessing blanchability is the primary method for evaluating early pressure injuries. If the redness blanches when gentle pressure is applied and returns to normal color, it indicates reactive hyperemia. Non-blanchable redness suggests potential Stage 1 pressure injury, requiring prompt intervention to prevent further tissue damage.
D. Assess elasticity of the surrounding tissue: Tissue turgor or elasticity provides information about hydration status but does not indicate whether the reddened area is a pressure-related injury. While useful for overall assessment, it is not the priority action when identifying early skin breakdown
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Rationale:
A. Hematocrit of 44% (0.44 volume fraction): This value falls within the normal reference range of 37%–47% for adult females. It indicates adequate red blood cell volume relative to plasma and does not require reporting to the healthcare provider.
B. Serum potassium 2.5 mEq/L (2.5 mmol/L): This value is below the normal range of 3.5–5.0 mEq/L, indicating hypokalemia. Low potassium levels can cause cardiac arrhythmias, muscle weakness, and respiratory compromise, necessitating immediate notification of the healthcare provider for intervention.
C. Hemoglobin 13 grams/dL (130 g/L): Hemoglobin within the range of 12–16 g/dL reflects adequate oxygen-carrying capacity and red blood cell mass. No abnormality is indicated, so it does not require reporting.
D. Serum sodium 125 mEq/L (125 mmol/L): This value is below the normal sodium range of 136–145 mEq/L, indicating hyponatremia. Hyponatremia can lead to neurological symptoms such as confusion, seizures, or lethargy, making it essential to report to the healthcare provider promptly.
E. White blood cell count 15,000/mm3 (15 x 10⁹/L): A WBC count above the reference range of 5,000–10,000/mm3 suggests leukocytosis, which may indicate infection, inflammation, or stress response. This abnormal finding should be communicated to the healthcare provider for further evaluation and management.
Correct Answer is A
Explanation
Rationale:
A. Pleural friction rub: A pleural friction rub is a low-pitched, dry, grating sound heard during both inspiration and expiration. It occurs when inflamed pleural surfaces rub together and is usually not cleared by coughing. It often indicates pleuritis or other conditions causing pleural inflammation and may be associated with pain during deep breaths.
B. Wheezing: Wheezing is a high-pitched, musical sound usually heard during expiration and sometimes inspiration, caused by narrowed airways due to bronchospasm, inflammation, or obstruction. It differs from a pleural friction rub in pitch, timing, and origin, and is often associated with asthma or COPD.
C. Coarse rhonchi: Coarse rhonchi are low-pitched, rattling lung sounds caused by secretions in larger airways. They may change or clear with coughing, unlike pleural friction rubs, which are persistent and unaffected by coughing.
D. Stridor: Stridor is a harsh, high-pitched sound heard primarily during inspiration and is caused by upper airway obstruction. It is distinct from a pleural friction rub in both location and mechanism, indicating obstruction rather than pleural inflammation.
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