The nurse is assessing an older client's skin for turgor. What body area is best for this assessment?
Sacral area
Sternum
Back of the hand
Axillary region
The Correct Answer is B
A. Sacral area: The sacral area is commonly used to assess for pressure injuries, especially in bedridden patients, but it is not ideal for assessing skin turgor. In older adults, the skin over the sacrum may be affected by chronic edema, thinning, or immobility, which can give misleading results when assessing elasticity.
B. Sternum: The sternum is the preferred site for assessing skin turgor in older adults because the skin here is less affected by age-related laxity and subcutaneous fat loss compared with extremities. Pinching the skin over the sternum provides a more accurate indication of hydration status and elasticity without interference from normal aging changes.
C. Back of the hand: In older adults, the skin on the hands tends to be thin, wrinkled, and less elastic due to aging, which can lead to false-positive signs of dehydration when assessing turgor. This makes it an unreliable site for hydration assessment.
D. Axillary region: The axilla is warm and moist, which can make it difficult to accurately assess skin turgor. Additionally, skin in this area is not typically tested for elasticity or hydration, as it is more prone to variability and environmental influence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Notify the physician immediately of this unexpected finding: While loss of suction should be reported if it cannot be corrected, immediate notification is not the first action. The nurse should first attempt standard troubleshooting to re-establish suction, as this is often a correctable issue without needing urgent physician intervention.
B. Allow gravity to assist with draining by repositioning the drain to a position lower than the client: Positioning the drain lower may facilitate passive drainage, but it does not restore the negative pressure needed for the Jackson-Pratt drain to function effectively. Relying solely on gravity can lead to fluid accumulation and increase the risk of infection.
C. Re-establish the negative pressure by opening the valve and decompressing the bulb: The Jackson-Pratt drain relies on negative suction to remove fluid from the wound site. If suction is lost, the nurse should compress the bulb after emptying it and closing the valve to restore negative pressure, ensuring continued drainage and reducing the risk of hematoma, or infection.
D. Switch the client's drain to a Hemovac drain to improve suction: Replacing the drain is not the first-line action. Hemovac drains are a different device, and switching requires a physician’s order. The priority is to troubleshoot and restore the function of the existing Jackson-Pratt drain before considering device replacement.
Correct Answer is ["90.9"]
Explanation
Calculation:
- Identify the total volume and infusion time
Total Volume: 1000 mL
Time: 11 hours
- Calculate the flow rate
Flow Rate (mL/hr) = Total Volume ÷ Time
Flow Rate = 1000 ÷ 11
Flow Rate ≈ 90.909
- Round to the nearest tenth
= 90.9 mL/hr
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