You have received a report and are providing skin care for the following patients. Which patient do you want to assess first?

A 58-year-old patient with uncontrolled diabetes mellitus type two and intact skin.

A 48-year-old patient with poor nutrition, warmth and edema to the coccyx.

An 82-year-old patient with a surgical incision and approximated wound edges.

A 69 year old patient with a colostomy and blanchable erythema to the sacrum.

Answer and Explanation

The Correct Answer is B

A. 58-year-old patient with uncontrolled diabetes mellitus type 2 and intact skin: While diabetes increases the risk of delayed wound healing and infection, intact skin is not an immediate concern.

B. 48-year-old patient with poor nutrition, warmth, and edema to the coccyx: Warmth and edema at a pressure site may indicate the beginning of a pressure injury or infection (e.g., cellulitis). Poor nutrition further increases the risk of skin breakdown and impaired healing, making this patient the priority for assessment.

C. 82-year-old patient with a surgical incision and approximated wound edges: A well-approximated surgical incision suggests healing is progressing normally, making this patient lower priority.

D. 69-year-old patient with a colostomy and blanchable erythema to the sacrum: Blanchable erythema is an early sign of pressure injury, but it is less concerning than warmth and edema, which suggest possible infection or worsening tissue damage.

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Correct Answer is D

Explanation

A. Elbows and behind the ears: These areas are not primary pressure points in a seated position.

B. Coccyx and back of the skull: The coccyx is a pressure point when lying down, but this patient is sitting most of the time.

C. Heels and trochanter: Heels are at risk in supine patients, but this patient is primarily sitting.

D. Sacrum and ischium: The sacrum and ischium (sit bones) bear the most pressure in a seated position, making them highly vulnerable to skin breakdown.

A. It is painful to sit on a bedpan. B. The position encourages the Valsalva maneuver. C. The position does not facilitate downward pressure. D. The cause is unknown and requires further study.

Correct Answer is C

Explanation

A. It is painful to sit on a bedpan. Discomfort may be a factor, but pain alone does not explain the difficulty in having a bowel movement.
B. The position encourages the Valsalva maneuver. The Valsalva maneuver (straining against a closed airway) can occur in any position, but posture is the primary problem here.
C. The position does not facilitate downward pressure. The seated position allows for gravity and proper abdominal muscle engagement, making defecation easier. Lying down does not facilitate intra-abdominal pressure.
D. The cause is unknown and requires further study. The relationship between position and defecation is well understood in physiology.

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Stoma Assessment	Stoma is protruding 2cm, is red and moist. Peristomal area is clean and intact.
Output	Liquid stool that is malodorous. Gas present in the appliance.
General Status	Patient is avoiding looking at the ileostomy during care.
Laboratory Data	Potassium 3.6 mEq/L (normal 3.5 to 5 mEq/L) Sodium 137 mEq/L (normal 135 to 145 mEq/L) Creatinine 0.9 mg/dL (normal 0.6 to 1.2 mg/dL)

You have received a report and are providing skin care for the following patients. Which patient do you want to assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult patient with chronic obstructive pulmonary disease. The patient always remains in a sitting position to help them breathe more easily. Based on this information, what area on the patient's body should be frequently assessed for skin breakdown?

Correct Answer is D

Explanation

A client is having difficulty having a bowel movement laying on the bedpan. What is the physiologic reason for this problem?

Correct Answer is C

Explanation

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