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 C

Explanation

A. Avoid bathing this patient until they are stable: Hygiene is essential for preventing infection and promoting comfort. Bathing should not be entirely avoided unless the patient is critically unstable.

B. Only bathe the perineal area: While perineal care is important, other areas also require cleaning, and modifications can be made to prevent excessive exertion.

C. Perform the bath in a semi-Fowler's position: Semi-Fowler's position (30–45°) promotes lung expansion and reduces dyspnea, making it the best position for bathing a patient with breathing difficulty.

D. Delegate the task to the assistive personnel: While an assistive personnel (AP) can assist, the nurse should assess the patient first and be involved in care for clients with respiratory distress.

A. 89-year-old with dementia and NG tube with continuous tube feeding B. 73-year old with hypoactive bowel sounds one day post cholecystectomy. C. 43 year old with anorexia and nausea for two days who is tolerating a clear liquid diet D. 65 year old with who has dysphagia after suffering from a stroke who is NPO

Correct Answer is D

Explanation

A. 89-year-old with dementia and NG tube with continuous tube feeding: While this patient requires monitoring, continuous tube feeding is routine, and there is no indication of immediate distress.

B. 73-year-old with hypoactive bowel sounds one day post-cholecystectomy: Hypoactive bowel sounds are expected after surgery, particularly after abdominal procedures. This does not indicate an emergency.

C. 43-year-old with anorexia and nausea for two days who is tolerating a clear liquid diet: This patient’s condition is stable, and nausea is resolving, making them a lower priority.

D. 65-year-old who has dysphagia after suffering from a stroke who is NPO: Dysphagia (difficulty swallowing) increases the risk of aspiration pneumonia, which can be life-threatening. This patient should be assessed first to ensure their airway is protected.

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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 preparing to bathe a client with dyspnea. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

The nurse has received a report for the following patients. Which patient should be seen first?

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?

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