The nurse is performing a head-to-toe assessment on a patient. The nurse uses their thumb and first finger to lift or pinch a fold of skin under the clavicle to check for skin turgor. Which of the following findings would be considered normal for this assessment?
Skin fold is difficult to lift/pinch.
Skin fold is released and an indentation of 2 mm remains.
Skin fold returns to its usual shape quickly when released.
Skin fold returns to its usual shape slowly when released.
The Correct Answer is C
The correct answer is choice C: Skin fold returns to its usual shape quickly when released. When assessing skin turgor, the nurse is checking for the elasticity and hydration of the skin. In a normal assessment, when the skin fold is lifted or pinched, it should return to its usual shape quickly when released. This indicates good skin turgor, which is an indication of proper hydration. If the skin fold is difficult to lift or pinch (choice A), this indicates poor skin turgor and possible dehydration. If an indentation of 2 mm remains after releasing the skin fold (choice B), this indicates poor skin turgor and possible dehydration. If the skin fold returns to its usual shape slowly when released (choice D), this may indicate a decrease in skin elasticity and possible dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Call a code and begin resuscitating the client.
In a situation where a client is unresponsive, not breathing, and without a carotid pulse, the priority is to initiate emergency resuscitation measures. The nurse should call a code and begin resuscitating the client immediately, regardless of any prior conversations or wishes that the client may have expressed. If there is no DNR order on the client's chart, it is assumed that the client would want to be resuscitated in such an emergency situation. It is not appropriate for the nurse to make a decision based on a conversation that may or may not have taken place in the past without documentation or a valid DNR order. It is important to act quickly and follow emergency protocols to provide the best chance of survival for the client. After the resuscitation measures have been initiated, the healthcare team can reassess the situation and make decisions based on the client's condition and wishes, if known.
Correct Answer is B
Explanation
The correct answer is choice B, safety measures necessary to prevent a fire. When teaching a home care client and their family about using prescribed oxygen, safety measures are critical. Oxygen supports combustion, so it is important to follow safety measures to prevent a fire. These safety measures include avoiding smoking, using electric razors instead of a blade, and avoiding flammable products such as oils, aerosol sprays, and alcohol-based hand sanitizers near the oxygen source. The oxygen should be kept away from heat sources and the tubing should be free from kinks or damage. The healthcare provider's phone number should also be readily available in case of any questions or emergencies.
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