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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Hypoxia is a medical condition characterized by a lack of oxygen in the body's tissues, which can occur due to a variety of reasons, such as respiratory failure, cardiac arrest, or other serious medical conditions. Cyanosis occurs when the oxygen saturation level in the blood falls below 85%, which causes a bluish color to appear on the skin, especially on the lips and fingertips. Therefore, if a nurse observes cyanosis in a patient's lips, it is a significant sign of hypoxia, and the patient requires immediate medical attention.
Correct Answer is C
Explanation
The normal range for respiratory rate in adults is typically between 12 to 20 breaths per minute, butsome individuals may have a slightly higher or lower respiratory rate within the normal range.
Options a and b are incorrect. Bowel sounds of 5-30 per minute are within the normal range, but this finding alone does not indicate that the patient is ready to go home. Capillary refill of greater than 3 seconds is considered abnormal and may indicate poor peripheral perfusion.
Option d is also incorrect. A heart rate of 10 is extremely low and would be considered bradycardia. This could indicate an underlying medical issue and would require further assessment and intervention before the patient is discharged.
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