The nurse is completing an assessment of the patient's skin integrity. Which assessment is the priority?

Pressure points

Pulse points

Breath sounds

Bowel sounds

Answer and Explanation

The Correct Answer is A

A. Pressure points: Pressure points (e.g., sacrum, heels, elbows, shoulders, hips) are at the highest risk for breakdown, ulcers, and impaired circulation. This makes them the priority assessment for skin integrity.

B. Pulse points: While checking pulses is important for circulatory assessment, it is not directly related to skin integrity assessment.

C. Breath sounds: Breath sounds assess respiratory function and are not a direct indicator of skin integrity.

D. Bowel sounds: Bowel sounds assess gastrointestinal function and are not relevant in a skin integrity assessment.

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Correct Answer is C

Explanation

A. Shortness of breath: While respiratory issues can reduce oxygenation and indirectly affect healing, shortness of breath is not a direct risk factor for pressure ulcer development.

B. Adequate dietary intake: Adequate nutrition prevents pressure ulcers rather than increasing the risk. Poor dietary intake, particularly protein and vitamin deficiencies, is a risk factor.

C. Decreased level of consciousness: Patients with a decreased level of consciousness (e.g., sedated, comatose, or confused patients) are at higher risk for pressure ulcers due to immobility, lack of repositioning, and unawareness of discomfort.

D. Muscular pain: While pain can limit movement, it is not a primary risk factor for pressure ulcer development. Immobility and prolonged pressure are the key contributors.

A. Utilizing evidence-based practice based on nurses' needs B. Establishes minimal passing standards for testing C. Uses critical thinking for the highest level of quality nursing care. D. By passes the patient's feelings to promote ethical standards

Correct Answer is C

Explanation

A. Utilizing evidence-based practice based on nurses' needs: Professional standards focus on patient-centered care, not the nurse's needs. Evidence-based practice should prioritize patient safety and effectiveness.

B. Establishes minimal passing standards for testing: While professional standards guide nursing education and testing, their primary role is to guide clinical decision-making for patient care.

C. Uses critical thinking for the highest level of quality nursing care: Professional standards provide guidelines for best practices, ensuring nurses apply critical thinking and clinical judgment to improve patient outcomes.

D. Bypasses the patient's feelings to promote ethical standards: Ethical nursing practice includes patient advocacy, not bypassing patient emotions or concerns.

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The nurse is completing an assessment of the patient's skin integrity. Which assessment is the priority?

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Naxlex Comprehensive Predictor Exams

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