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 C

Explanation

A. Massaging red bony prominences may cause further skin damage and increase the risk of pressure ulcers.

B. Skin should be assessed for warmth, redness, and integrity, but coolness is not necessarily an indicator of pressure injury.

C. Repositioning every 2 hours is essential for preventing pressure ulcers in bed-bound clients by relieving pressure on vulnerable areas.

D. Keeping the skin moist increases the risk of skin breakdown. It is important to keep the skin dry and clean.

A. Keep the client's skin dry with powder. B. Implement turning schedule every 4 hr. C. Massage over erythematous bony prominences. D. Use pillows to keep heels off the bed surface. E. Minimize skin exposure to moisture.

Correct Answer is ["D","E"]

Explanation

A. Using powder can cause skin irritation and dryness and is not recommended for preventing skin breakdown.

B. Clients should be repositioned at least every 2 hours, not every 4 hours, to prevent pressure ulcers.

C. Massaging over erythematous areas can damage fragile tissue and increase the risk of skin breakdown.

D. Using pillows to keep heels off the bed surface helps relieve pressure on bony prominences, reducing the risk of pressure ulcers.

E. Minimizing skin exposure to moisture prevents maceration and skin breakdown, especially in incontinent clients.

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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 planning care for a client who is confined to bed. Which of the following actions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

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