The nurse assesses for skin turgor and notes tenting of the chest wall skin. This finding is likely due to which of the following conditions:

Fluid overload

Dehydration

Normal finding

Allergic reaction

Answer and Explanation

The Correct Answer is B

A. Fluid overload: Fluid overload more commonly causes edema and taut, boggy skin rather than skin tenting.

B. Dehydration: Tenting (skin that stays elevated when pinched) reflects decreased skin turgor from loss of interstitial fluid and is a classic sign of dehydration.

C. Normal finding: Good skin turgor is normal; persistent tenting is not a normal finding and indicates abnormal fluid status.

D. Allergic reaction: Allergic reactions typically cause hives, erythema, or swelling; they do not produce the characteristic tenting seen with reduced skin turgor.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Stage I pressure injury is characterized by intact skin with a localized area of nonblanchable erythema (redness). The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. The patient in the prompt has intact skin on their heel with a nonblanchable reddish area, which fits this description perfectly.

B. STAGE II: A Stage II pressure injury involves partial-thickness loss of the dermis. It presents as a shallow open ulcer with a red or pink wound bed, without slough or bruising. It may also present as an intact or ruptured serum-filled blister. Since the patient's skin is intact, Stage II is incorrect.

C. STAGE III: A Stage III pressure injury involves full-thickness skin loss, where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough and/or eschar may be present. This is a much more severe injury than what is described.

D. STAGE IV: A Stage IV pressure injury involves full-thickness skin and tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. This is the most severe stage and is clearly not what is pictured or described.

A. Due to increase in physical activity B. Increase in subcutaneous body fat and metabolic rate C. Due to an increase in protein intake in their diet D. Decrease in subcutaneous body fat and metabolic rate

Correct Answer is D

Explanation

A. Due to increase in physical activity: Increased activity tends to raise body temperature; older adults typically have lower activity levels, so this does not explain a lower baseline temperature.

B. Increase in subcutaneous body fat and metabolic rate: Increased subcutaneous fat and metabolic rate would tend to conserve heat and raise temperature; aging is associated with the opposite change.

C. Due to an increase in protein intake in their diet: Dietary protein does not directly cause a lower core body temperature in older adults.

D. Decrease in subcutaneous body fat and metabolic rate: Age-related loss of subcutaneous fat and a lower metabolic rate reduce heat production and insulation, contributing to a tendency toward lower body temperature.

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

The nurse assesses for skin turgor and notes tenting of the chest wall skin. This finding is likely due to which of the following conditions:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While performing a skin assessment on a bedridden patient, you note a reddish area on the patient's left heel. The skin is intact. The area is nonblanchable. See the picture below. Based on your findings, you suspect this may be which of the following pressure injury?

Correct Answer is A

Explanation

A nurse caring for an 88-year-old client understands that the body temperature of older adults is prone to lower body temperature. The nurse understands this is most likely due to which of the following reasons:

Correct Answer is D

Explanation

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious lung sounds?

A nurse cares for a client with moderate drainage from a wound. The nurse needs to apply a highly absorbent dressing. Which type of dressings should the nurse use for this client?

The nurse assesses a patient who reports chest pain during inhalation and exhalation. The nurse notes upon auscultation, coarse sounds in rhythm with the breathing. The name of this clinical finding is which of the following?

A nurse notes a client's intercostal muscles are pulling inwards and reports difficulty breathing. The nurse would document which of the following to describe this type of abnormal breathing pattern:

A post-surgical patient reports feeling a "pop" in their surgical wound to the nurse. The nurse noted pinkish drainage on the client's dressing. Upon assessment, the nurse noted a protruding bowel loop. What should be the nurse's immediate action?

The nurse is caring for a post-operative client who underwent a left above-the-knee amputation 6 hours prior. Which of the following clinical findings should the nurse be most concerned with?

A client experienced a left above-the-knee amputation (AKA) due to a motorcycle accident one week prior. The client called the nurse, stating feeling burning pain on the surface of his left lower leg. The nurse understands the client is experiencing which of the following:

A client is prescribed Bentyl 20 mg PO TID. The drug is available in 10 mg capsules. How many capsules will he receive in 24 hours?