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 B

Explanation

A. "It is okay to take laxatives every day to help you have a bowel movement." Frequent laxative use can lead to dependence and decreased bowel function over time. Instead, non-pharmacologic measures such as fiber intake, hydration, and physical activity should be encouraged first.

B."Do not ignore the urge to have a bowel movement even if you feel it is inconvenient." Ignoring the urge can lead to constipation as stool remains in the colon longer, resulting in increased water absorption and harder stools. Encouraging regular bowel habits helps maintain normal function.

C. "Do not take opiate medications as those can cause constipation." While opiates can cause constipation, this statement is too broad. Some individuals may require opioid therapy for pain management. Instead, the focus should be on preventing and managing opioid-induced constipation rather than avoiding these medications altogether.

D. "Be sure to eat at least 20 grams of fiber and drink at least 1,000mL per day." While increasing fiber intake is important, 20 grams may not be sufficient (the recommended daily fiber intake for older adults is about 25–30 grams). Additionally, 1,000 mL (1 liter) of fluid may be inadequate, as older adults should aim for at least 1,500–2,000 mL per day unless contraindicated.

A. Educate the patient about hand hygiene with alcohol based hand sanitizer. B. Notify the patient's spouse about the result and arrange for HIV testing C. Provide information on antibiotic therapy to help control the infection. D. Initiate contact precautions with gown and gloves.

Correct Answer is A

Explanation

A. Educate the patient about hand hygiene with alcohol-based hand sanitizer: Standard precautions apply to all patients, including hand hygiene education. HIV is not transmitted through casual contact.

B. Notify the patient's spouse about the result and arrange for HIV testing: Patient confidentiality must be maintained. The patient should be encouraged to inform their partner, but the nurse cannot disclose the results.

C. Provide information on antibiotic therapy to help control the infection: HIV is a viral infection, not bacterial. Antibiotics do not treat HIV.

D. Initiate contact precautions with gown and gloves: HIV is bloodborne and not spread via casual contact, so contact precautions are not required unless the patient has an open wound or secondary infection.

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Laboratory Test	Reference Range	Patient Results
White Blood Cells	5,000- 10,000/mm3	9,500/mm3
Neutrophil Count	2.500-8,000/mm3	5,200/mm3
HIV	Negative	Positive

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

The nurse is providing education on how to prevent constipation to a group of older adults in a nursing facility. What should be included in the education?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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