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

Pressure points

Breath sounds

Pulse points

Bowel sounds

Answer and Explanation

The Correct Answer is A

A. Pressure points are critical to assess when evaluating skin integrity, particularly in patients who are immobile or bedridden, as these areas are at high risk for pressure ulcers.

B. Breath sounds are important but are not the priority in assessing skin integrity.

C. Pulse points assess circulation, but they are not directly related to skin integrity.

D. Bowel sounds are relevant for digestive assessments, not for skin integrity.

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Correct Answer is A

Explanation

A. Docusate sodium is a stool softener, and it may take 1-3 days to produce a bowel movement, so this statement reflects proper understanding.

B. Docusate is used to prevent constipation, not treat diarrhea, so this statement is incorrect.

C. Taking docusate sodium with mineral oil can increase the risk of absorption of mineral oil into the system, which is harmful, so this combination should be avoided.

D. The client should drink plenty of fluids, around 8 ounces or more, to help soften the stool.

A. Include intact skin at the wound edges in the culture B. Irrigate the wound with an antiseptic prior to obtaining the specimen C. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen D. Swab an area of skin away from the wound to identify the usual flora

Correct Answer is C

Explanation

A. Including intact skin in the culture would not accurately reflect the bacteria present in the wound itself.

B. Irrigating with an antiseptic may alter the bacterial flora, potentially leading to inaccurate culture results.

C. Cleansing the wound with 0.9% sodium chloride helps remove surface contaminants without affecting the bacterial culture from the wound bed.

D. Swabbing away from the wound does not provide information about the organisms causing the infection.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who takes opioid pain medication and has a new prescription for docusate sodium. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

Correct Answer is C

Explanation

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