A client who has been hospitalized with an exacerbation of heart failure experiences severe dyspnea with activity and remains on bedrest. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

Thick, dry, and dark area on bilateral heels.

Broken skin without evidence of undermining.

Defined area of persistent redness over bone.

Superficial sacral ulcer with defined margins.

Answer and Explanation

The Correct Answer is C

Choice A reason: Thick, dry, dark areas on heels suggest chronic skin changes, not early pressure ulcers. Persistent redness over bone is the earliest sign (Stage 1). This indicates later damage, per pressure injury staging and prevention protocols in nursing care for immobile clients.

Choice B reason: Broken skin indicates a Stage 2 pressure ulcer, beyond the earliest stage. Persistent redness (Stage 1) signals initial tissue compromise. Broken skin requires intervention but is not the earliest sign, per pressure ulcer assessment and prevention standards in nursing practice.

Choice C reason: Persistent redness over bone is the earliest sign of a Stage 1 pressure ulcer, indicating tissue compromise due to pressure. Early intervention prevents progression in bedrest clients with heart failure, per pressure injury prevention and skin assessment protocols in nursing care.

Choice D reason: A superficial sacral ulcer (Stage 2) is more advanced than persistent redness (Stage 1), the earliest sign. Redness allows earlier intervention to prevent ulceration. Ulcers indicate progression, per pressure ulcer staging and prevention guidelines for immobile clients in nursing.

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Correct Answer is A

Explanation

Choice A reason: Clear breath sounds indicate effective suctioning, as it removes secretions obstructing the airway, improving ventilation. This aligns with the goal of endotracheal suctioning to maintain airway patency, ensuring adequate oxygenation and reducing infection risk, per critical care and respiratory management protocols in nursing practice.

Choice B reason: Increased respiratory rate suggests respiratory distress, indicating ineffective suctioning. Clear breath sounds confirm secretion removal, ensuring airway patency. A rising rate may reflect persistent obstruction or hypoxia, requiring further intervention, per respiratory assessment and critical care standards for endotracheal tube management in nursing.

Choice C reason: Decreased oxygen saturation indicates ineffective suctioning, as secretions likely remain, impairing oxygenation. Clear breath sounds confirm airway clearance, improving gas exchange. Low saturation requires immediate reassessment, per oxygenation monitoring and critical care protocols for clients with endotracheal tubes in nursing practice.

Choice D reason: Presence of wheezing suggests airway narrowing or persistent secretions, indicating ineffective suctioning. Clear breath sounds demonstrate successful secretion removal, ensuring unobstructed airflow. Wheezing requires further intervention, per respiratory assessment and airway management standards in critical care nursing for intubated clients.

A. Question the client about related symptoms. B. Palpate the inguinal area for a bulge. C. Inspect the urethral meatus for abnormalities. D. Observe the scrotum for swelling.

Correct Answer is A

Explanation

Choice A reason: Questioning about related symptoms (e.g., urgency, frequency) clarifies nocturia and hesitancy, suggesting causes like benign prostatic hyperplasia. This comprehensive data guides targeted assessments, ensuring accurate diagnosis and treatment, per urological assessment and patient history standards in elderly male nursing care.

Choice B reason: Palpating for an inguinal bulge assesses hernia, unrelated to nocturia or hesitancy. Questioning related symptoms better identifies urinary issues, guiding diagnosis. Hernias are not primary causes, per urological assessment and differential diagnosis protocols in nursing care for urinary complaints.

Choice C reason: Inspecting the meatus for abnormalities or discharge may follow but is less comprehensive than symptom questioning, which broadens the urinary history. Symptoms like hesitancy suggest internal issues, per urological assessment and benign prostatic hyperplasia diagnostic standards in nursing practice for elderly men.

Choice D reason: Observing scrotal swelling assesses testicular issues, not directly linked to nocturia or hesitancy. Questioning symptoms like weak stream or dribbling prioritizes urinary tract evaluation, per urological and geriatric assessment protocols in nursing care for male urinary symptoms.

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A client who has been hospitalized with an exacerbation of heart failure experiences severe dyspnea with activity and remains on bedrest. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After suctioning a client who has an endotracheal tube, which assessment finding indicates to the nurse that the intervention was effective?

Correct Answer is A

Explanation

An older male client reports nocturia with difficulty starting his urine stream. Which additional assessment should the nurse perform to obtain further data related to this information?

Correct Answer is A

Explanation

A client newly diagnosed with eczema tells the clinic nurse of using a heat lamp to dry the fluid-filled blisters localized in the left antecubital area. How should the nurse respond?

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