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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A. "I will administer the medications 10 minutes apart."Timing is important, but this option does not specify which medication should be taken first. The correct sequence is albuterol first, followed by cromolyn.
B. "I will use both medications immediately after exercising." Cromolyn is a mast cell stabilizer used for prevention, not acute symptoms. It should be taken 15-30 minutes before exercise to prevent exercise-induced bronchospasm, not after.
C. "I will be sure to take the albuterol before taking the cromolyn." Albuterol (a bronchodilator) should be taken first to open the airways, allowing better absorption of cromolyn (an anti-inflammatory medication).
D. "If my breathing begins to feel tight, I will use the cromolyn immediately." Cromolyn is not a rescue medication. Albuterol should be used for acute bronchospasm, while cromolyn is for long-term asthma control.
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