The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? Select all that apply.

Check skin for unusual bruising.

Palpate mucus membranes for cracks.

Monitor color of nailbeds.

Assess skin folds of perineal area.

Observe skin under the breasts.

Answer and Explanation

Correct Answer : D,E

A. Check skin for unusual bruising is not directly related to the client's diaphoretic condition. While bruising may be relevant in some cases, it is not the priority in this scenario, where the focus is on managing moisture and skin integrity.

B. Palpate mucus membranes for cracks is not as relevant in this situation. Cracks in the mucus membranes could indicate dehydration or other issues, but the primary concern for a diaphoretic client is skin breakdown due to moisture.

C. Monitor color of nailbeds is important in general assessment, but it is not directly related to the client's diaphoretic condition. Nailbed color may indicate circulation issues, but it is not a primary concern for this scenario.

D. Assess skin folds of perineal area is important because moisture from perspiration can accumulate in skin folds, increasing the risk for skin breakdown or infection, especially in overweight clients.

E. Observe skin under the breasts is also critical. The skin under the breasts is prone to moisture buildup, which can lead to irritation, fungal infections, or skin breakdown in overweight clients. Regular assessment of this area is necessary to prevent complications.

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Correct Answer is D

Explanation

A. Identify effective pain relief measures is important but not the first step in assessing pain quality. The nurse must first assess the pain itself before determining what interventions are effective.

B. Provide a numeric pain scale is commonly used to assess the intensity of pain, but it does not address the quality of pain. The numeric scale helps measure the severity, but it does not capture how the pain feels.

C. Observe body language and movement can provide clues about pain but does not give a comprehensive understanding of the pain's quality. While useful for assessing nonverbal clients, this approach alone does not provide detailed information about the pain experience.
D. Ask the client to describe the pain is the best approach for assessing the quality of pain. By asking the client to describe the pain, the nurse can gather information about its characteristics, such as sharp, dull, burning, or aching, which provides insight into the nature of the pain and helps guide appropriate interventions.

A. Apply sterile-strips. B. Obtain a wound culture. C. Apply a debriding agent. D. Remove every other suture.

Correct Answer is B

Explanation

A. Apply sterile-strips is not the most appropriate action. Steri-strips are typically used for approximating wound edges or supporting sutures, but they are not the first intervention when there is concern about infection or unusual exudate.

B. Obtain a wound culture is the correct action. A thick tan exudate may indicate infection or an abnormal healing process. The nurse should obtain a wound culture to identify the presence of infection and guide appropriate treatment.

C. Apply a debriding agent is premature without first assessing the wound for infection. Debridement is typically used to remove necrotic tissue, but the priority is to determine whether an infection is present before proceeding with debridement.

D. Remove every other suture is not indicated. Sutures should not be removed unless instructed by the healthcare provider, and there is no indication that sutures need to be removed at this time. The focus should be on assessing the wound for infection first.

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The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To assess the quality of an adult client's pain, which approach should the nurse use?

Correct Answer is D

Explanation

A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

Correct Answer is B

Explanation

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