How it Works
Try Naxlex NCLEX-RN (Free-Trial)

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

A.

Pressure points

B.

Pulse points

C.

Breath sounds

D.

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.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is ["1170"]

Explanation

Step 1: Convert cups and ounces to mL (1 cup = 240 mL, 1 oz = 30 mL):

  • Coffee: 1 cup = 240 mL
  • Orange juice: 4 oz × 30 mL = 120 mL
  • Water (first): 3 oz × 30 mL = 90 mL
  • Flavored gelatin: 1 cup = 240 mL
  • Tea: 1 cup = 240 mL
  • Broth: 5 oz × 30 mL = 150 mL
  • Water (second): 3 oz × 30 mL = 90 mL

Step 2: Add all the mL values together:
240 + 120 + 90 + 240 + 240 + 150 + 90 = 1,170 mL

Final Answer: 1,170 mL

Correct Answer is D

Explanation

A. Hypertension: Diphenhydramine (Benadryl) is an antihistamine that typically causes hypotension, not hypertension. It can have a mild vasodilatory effect, leading to a drop in blood pressure in some patients.

B. Constipation: While some antihistamines can cause mild gastrointestinal effects, constipation is not a primary adverse effect of diphenhydramine. Dry mouth and urinary retention are more common due to its anticholinergic properties.

C. Bradycardia: Diphenhydramine can sometimes cause tachycardia (increased heart rate), especially in elderly patients or those prone to cardiovascular effects. Bradycardia (slow heart rate) is not a usual adverse effect.

D. Sedation: Diphenhydramine is a first-generation antihistamine that crosses the blood-brain barrier and has a sedative effect by blocking histamine receptors in the central nervous system. It is commonly used as a sleep aid for this reason.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register