When you receive the shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate?

Redo the initial assessment and document current findings

Perform and document a focused assessment of skin integrity

Correct the initial assessment form

Conduct and document an emergency assessment

Answer and Explanation

The Correct Answer is B

A. Redo the initial assessment and document current findings:

This option suggests repeating the entire initial assessment. While reassessment is important, redoing the entire initial assessment may not be necessary. Instead, a focused assessment on the specific area of concern (skin integrity) is more appropriate.

B. Perform and document a focused assessment of skin integrity:

This is the recommended choice. If unexpected findings are observed during care, such as reddened areas over bony prominences, it is important to conduct a focused assessment on the skin to identify any issues and document the findings accurately.

C. Correct the initial assessment form:

Simply correcting the initial assessment form may not address the immediate need for assessing and addressing the reddened areas. It is more crucial to perform a focused assessment on the skin.

D. Conduct and document an emergency assessment:

Reddened areas over bony prominences may not necessarily indicate an emergency. However, addressing the issue promptly is important. A focused assessment would be more appropriate than conducting a full emergency assessment.

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

Explanation

A. Client reports feeling dizzy when sitting up from a supine position.

Dizziness or lightheadedness when moving from a lying down to a sitting or standing position can be indicative of orthostatic hypotension.

B. Client reports feeling palpitations when rising from a supine to a standing position.

Palpitations (feeling of rapid or irregular heartbeat) can be associated with orthostatic changes and may indicate the heart's compensatory response to low blood pressure.

C. Erythema is present on the bilateral lower extremities.

Erythema (redness of the skin) is not typically associated with orthostatic hypotension. This symptom is more likely related to skin conditions or other causes.

D. The client has a temperature of 100.4 F.

Fever (elevated body temperature) is not a direct symptom of orthostatic hypotension. Orthostatic hypotension is primarily related to changes in blood pressure upon assuming an upright position.

E. The client states, “I feel lightheaded when sitting up.”

Lightheadedness upon sitting up or standing is a common symptom of orthostatic hypotension.

A. Change the plan of care to provide different pain relief interventions B. Reassess the client to determine the reasons for inadequate pain relief C. Teach the client about the plan of care for managing his pain D. Wait to see whether the pain lessens during the next 24hours

Correct Answer is B

Explanation

A. Change the plan of care to provide different pain relief interventions:

While changing the plan of care may be necessary, it should be based on a thorough reassessment. Simply changing the plan without understanding the reasons for inadequate pain relief may not lead to effective outcomes.

B. Reassess the client to determine the reasons for inadequate pain relief.

Reassessment is a crucial step in the nursing process, especially when the desired outcomes are not achieved. By reassessing the client, the nurse can identify any factors contributing to the inadequate pain relief. This might include reevaluating the effectiveness of the current pain relief interventions, ensuring proper administration of medications, considering changes in the client's condition, or exploring any new factors affecting pain.

C. Teach the client about the plan of care for managing his pain:

Teaching is an important aspect, but in this case, reassessment takes precedence. Once the reasons for inadequate pain relief are determined, teaching can be tailored to address specific needs.

D. Wait to see whether the pain lessens during the next 24 hours:

If the pain is not adequately controlled, waiting for another 24 hours without action may prolong the client's discomfort and delay appropriate interventions. Reassessment and prompt adjustments to the plan of care are crucial for effective pain management.

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When you receive the shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is taking a blood pressure measurement to assess for orthostatic hypotension in a client. Which signs and symptoms will the nurse assess related to this condition? (Select all that apply.)

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

Explanation

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?

Correct Answer is B

Explanation

A nurse is preparing to measure a client’s level of oxygen saturation on a patient who has had a bilateral lower leg amputation. He noticed the patient’s hands are very edematous. The nurse should apply the pulse oximeter probe to which of the following locations?

A nurse is completing a client’s history and physical examination. Which of the following information should the nurse consider subjective data?

A nurse is caring for a client who has an electrical burn. With the client’s permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?

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A nurse is measuring a client’s oral temperature. The thermometer reads 33 C (91.4F). Which of the following actions should the nurse take? (Select all that apply)

Ordered: Potassium chloride (K-Dur) 60 mEq Available: Potassium chloride (K-Dur) 20 mEq/15 mL Administer: _____mL

A nurse performs an integumentary assessment of a client who has recently fallen and broken his leg. The nurse notes the skin coloring on the broken leg is bluish gray. What is the term for this change in skin color?

A patient is having dyspnea. What would the nurse do first?