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. Calcium channel blocker: Calcium channel blockers (e.g., amlodipine, diltiazem) do not commonly cause a dry cough. They primarily work by relaxing blood vessels and reducing heart workload.

B. Angiotensin II receptor blocker: ARBs (e.g., losartan, valsartan) do not typically cause a persistent cough. They are often prescribed instead of ACE inhibitors for patients who experience this side effect.

C. Angiotensin-converting enzyme (ACE) inhibitors: ACE inhibitors (e.g., lisinopril, enalapril) can cause a persistent dry cough due to the accumulation of bradykinin, a substance that can irritate the airways.

D. Beta-blockers: Beta-blockers (e.g., metoprolol, propranolol) are not commonly associated with a dry cough. They mainly affect heart rate and blood pressure but can cause bronchospasms in some patients.

A. Pleural effusion B. Hypoxemia C. Dysphagia D. Apnea

Correct Answer is B

Explanation

A. Pleural effusion: A pleural effusion is the accumulation of fluid in the pleural space and is not directly related to atelectasis. Atelectasis is alveolar collapse and does not cause fluid buildup.

B. Hypoxemia: Atelectasis impairs gas exchange, leading to decreased oxygen levels (hypoxemia) due to collapsed alveoli. This is a hallmark finding.

C. Dysphagia: Dysphagia (difficulty swallowing) is not a direct symptom of atelectasis. It may be seen in stroke or esophageal disorders.

D. Apnea: Apnea (cessation of breathing) is not a typical sign of atelectasis. Atelectasis causes shallow breathing, dyspnea, and hypoxia rather than complete cessation.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

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