In performing a focused assessment, the practical nurse (PN) lifts the client's skin as seen in the photo. Which should the PN do next?

Assess the degree of skin elasticity.

Record palpated skin temperature.

Measure the depth of indentation.

Observe for swelling and inflammation.

Answer and Explanation

The Correct Answer is A

A. Lifting the skin is a common technique used to assess skin turgor, which is the elasticity of the skin.By letting go, the nurse can observe how quickly the skin snaps back into place, indicating good or poor elasticity.
B. recording palpated temperature might be done during a focused assessment, but it wouldn't necessarily be the next step after lifting the skin.
C. measuring indentation depth might be relevant for assessing edema (swelling), but it's not the primary focus after lifting for turgor.
D. observing swelling could be assessed visually without lifting the skin, and while it's important, assessing elasticity comes first in this scenario.

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Correct Answer is C

Explanation

A. Describing the procedure in detail can increase anxiety or focus the client on the pain rather than distracting them from it.
B. Asking the client to describe the pain could heighten their awareness of it, which is counterproductive to the goal of distraction.
C. Encouraging the client to reminisce about a favorite past family event is a distraction technique that shifts the client's focus away from the pain, helping to manage discomfort during the procedure.
D. Explaining alternative pain management strategies is useful but not a distraction technique; it does not provide immediate relief or shift the client's focus during the procedure.

A. Plan to re-assess the client's temperature in two hours. B. Notify the charge nurse of the assessment findings. C. Measure and record the client's intake and output. D. Provide oral hygiene on a regular, frequent schedule.

Correct Answer is B

Explanation

A. Re-assessing the client’s temperature is important but not the priority action since the client is currently afebrile and the cough with yellow sputum could indicate an infection or other condition needing immediate attention.
B. Notifying the charge nurse of the assessment findings is the priority because the yellow-tinged sputum in a client receiving chemotherapy might indicate an infection or complication that requires further investigation and possible intervention.
C. Measuring and recording intake and output is important for overall fluid balance but does not address the immediate concern of a productive cough with potential infection.
D. Providing regular oral hygiene is part of general care but does not address the potential underlying cause of the productive cough and yellow-tinged sputum.

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In performing a focused assessment, the practical nurse (PN) lifts the client's skin as seen in the photo. Which should the PN do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) plans to use distraction techniques while a client undergoes a brief painful procedure. Which action should the PN implement during the procedure?

Correct Answer is C

Explanation

A client receiving chemotherapy develops a cough that is productive of yellow-tinged sputum. After determining that the client is afebrile, which is the priority action for the practical nurse (PN) to take?

Correct Answer is B

Explanation

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