The nurse noted which of the following about the patient’s skin during her monitoring assessment. (Select all that apply)
Tachypnea
Temperature
Turgor
Tympany
Correct Answer : B,C
Normal skin temperature for healthy adults ranges between 92.3 and 98.4 Fahrenheit or 33-37 Celsius, far lower than the 98.6 F average core temp. Changes in skin temperature may indicate potential illness or injuries.
To check for skin turgor, the healthcare provider grasps the skin between two fingers so that it is tented up. Commonly the lower arm or abdomen is checked. The skin is held for a few seconds and then released. Skin with normal turgor snaps rapidly back to its normal position.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When assessing the abdomen, the nurse would expect to auscultate bowel sounds, which are the sounds made by the movement of gas and fluid through the intestines. The normal bowel sounds are characterized as high-pitched, gurgling, and occurring at a rate of 5-30 sounds per minute.

Bruits are abnormal sounds indicating turbulent blood flow and are usually assessed in other areas of the body, such as the epigastric and renal arteries, as well as in the aorta.
Friction rubs are also abnormal sounds, but they are typically heard during auscultation of the heart and lungs.
Low-pitched sonorous sounds are not typical sounds that are expected to be heard during an abdominal assessment
Correct Answer is B
Explanation
The SBAR (Situation, Background, Assessment, Recommendation) system is a standardized way of communicating critical information between healthcare professionals, particularly during patient handoffs or when escalating a concern.
The recommendation component is where the healthcare professional providing the report suggests a course of action or plan for the patient based on the situation, background, and assessment. For example, a recommendation might be, "I recommend increasing Mr. Smith's pain medication to manage his discomfort," or "I recommend a consult with the nutritionist to address Mrs. Brown's malnutrition."

Of the options provided, (a) provides the situation, (c) provides the assessment, and (d) provides a specific finding from the assessment. Option (b) is a specific recommendation or plan.
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