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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is choice A, "Carbohydrates, proteins, and lipids." These three nutrients are macronutrients and supply the body with energy when consumed. Carbohydrates provide 4 kilocalories (kcal) per gram, proteins provide 4 kcal per gram, and lipids (fats) provide 9 kcal per gram. Vitamins, minerals, and water are essential for overall health and body function, but they do not supply energy to the same extent as macronutrients.

A. Recognize this as a normal PVR and document the amount in the patient's chart. B. Recognize this as an abnormal PVR, call the physician, and recommend an external catheter be applied. C. Recognize this as an abnormal PVR, call the physician, and obtain an order for an in-and-out catheterization. D. Recognize this as an abnormal PVR and try to have the client void again in a few hours.

Correct Answer is C

Explanation

A.This option is incorrect because a PVR of 400 mL is significantly higher than normal. Documenting without further intervention could lead to complications if the high residual volume persists.

B.While an external catheter may be beneficial for managing incontinence or monitoring urine output, it does not address the underlying issue of urinary retention. An external catheter would not relieve the retained urine in the bladder.

C.A post-void residual (PVR) of 400 mL is abnormally high, indicating that the bladder is not emptying effectively, which can lead to discomfort, urinary tract infection (UTI), and potential kidney issues if left untreated. An in-and-out catheterization allows for temporary relief by emptying the bladder and can also help prevent bladder distention. Contacting the physician to report the findings and obtain an order is appropriate to manage this condition safely.

D. Encouraging the client to attempt voiding again without intervention may not be effective in reducing the high PVR. This delay could increase the risk of bladder distention and discomfort.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A dietitian is providing an in-service for the nurses on a medical-surgical unit. During the in-service, the dietitian informs the group that there are six classes of nutrients, and three supply the body with energy. Which of the following are the three energy-supplying nutrients?

Correct Answer is A

Explanation

A client had his Foley catheter removed six hours ago and has just voided for the first time. The nurse performs a bladder scan to check for any post-void residual. The results of the post-void residual (PVR) from the bladder scan are 400mL of urine. What should the nurse do next?

Correct Answer is C

Explanation

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