During a skin assessment, which finding should the nurse report immediately?

Non-blanching purple area over the sacrum

Small healed scar on the arm

Freckles on the shoulders

Dry skin on the lower legs

Answer and Explanation

The Correct Answer is A

Rationale:
A. This is a critical finding that indicates possible pressure injury (pressure ulcer) or tissue ischemia. Non-blanching means that when pressure is applied, the area does not turn white, which is a hallmark sign of compromised perfusion and potential skin breakdown. Immediate reporting is necessary to prevent further tissue damage and initiate interventions such as pressure relief, wound care, and close monitoring.

B. This is an old, healed injury and is considered normal in the context of a skin assessment. It does not indicate current skin compromise and does not require urgent reporting.

C. Freckles are benign pigmented skin lesions. They are normal variations in skin pigmentation and do not indicate acute pathology or require immediate reporting.

D. While dry skin should be addressed to prevent discomfort or cracking, it is not an urgent finding. It can be managed with routine skin care and moisturizer, and does not require immediate intervention.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Explanation

Rationale:

Temperature: Worsened. Increased from 38.2°C to 38.6°C, indicating a slight rise in fever.
Pulse oximetry: Improved. Oxygen saturation improved from 85% to 95% after oxygen therapy and interventions.
Respiratory rate: Improved. Rate decreased from 32/min to 22/min, showing reduced work of breathing.
Blood pressure: Unchanged. BP remained stable at 112/56 mm Hg.
Mucous membrane color: Improved. Color changed from pale to pink, indicating improved oxygenation and perfusion.

A. To provide a structured method for nurses to document patient care plans. B. To enhance patient safety by standardizing communication during handoffs and critical situations. C. To facilitate the electronic medical record (EMR) entry process. D. To ensure compliance with hospital policies and procedures.

Correct Answer is B

Explanation

Rationale:
A. SBAR is not primarily used for documenting patient care plans. While documentation is an important aspect of nursing practice, SBAR is specifically designed as a communication framework rather than a documentation tool. Therefore, this option is incorrect.

B. SBAR (Situation, Background, Assessment, Recommendation) is a standardized communication tool used to ensure clear, concise, and organized exchange of critical patient information, especially during handoffs and urgent situations. It reduces miscommunication, promotes clarity, and improves patient safety. This is the correct answer because it reflects the primary purpose of SBAR in clinical practice.

C. SBAR is not intended to facilitate electronic medical record (EMR) entry. Although it may indirectly support organized thinking that could help with documentation, its main role is verbal and written communication between healthcare providers, not EMR processing. This option is incorrect.

D. While SBAR may support adherence to hospital policies by promoting effective communication, its primary purpose is not policy compliance. Instead, it is focused on improving communication efficiency and patient safety. Therefore, this option is incorrect.

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During a skin assessment, which finding should the nurse report immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. For each finding at 1100, click to specify if the finding indicates that the client's condition has improved, worsened, or is unchanged.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Explanation

Which of the following best describes the purpose of using the SBAR communication tool in nursing practice?

Correct Answer is B

Explanation

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