A nurse is assessing the skin turgor of an older adult client. In which of the following areas should the nurse lift the skin?

Abdomen

Shoulder

Stomach

Neck

Answer and Explanation

The Correct Answer is D

Choice A reason

Abdomen area is not appropriate: Assessing skin turgor on the abdomen is not commonly performed. The abdomen may not be the most accurate site for assessing skin turgor, especially in older adults, as it can be influenced by factors such as body fat distribution.

Choice B reason:

Shoulder are is not appropriate: The shoulder is not a typical site for assessing skin turgor. It is generally not used for this purpose, as it may not provide reliable results

Choice C reason:

Stomach is not the correct answer.: Assessing skin turgor on the stomach is also not commonly performed. The abdomen or stomach may not be the most accurate site for assessing skin turgor, especially in older adults.

Choice D reason

When assessing skin turgor in an older adult client, the nurse should lift the skin on the neck to evaluate its elasticity and hydration status. Skin turgor is a measure of skin's elasticity and is commonly used as an indicator of hydration in both adults and older adults.

To assess skin turgor, the nurse will gently pinch a small amount of skin on the back of the client's hand or the front of the chest (sternum). However, since the options listed do not include these areas, the closest alternative for an older adult would be the neck.

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Correct Answer is D

Explanation

The correct answer is choice D. Place a wedge under one of the client’s hips. This is because placing a wedge under one of the hips can help prevent compression of the inferior vena cava by the uterus, which can compromise placental blood flow and cause fetal hypoxia. Placing a wedge under the hip can also help reduce the risk of maternal hypotension, which can also affect fetal oxygenation.

Choice A is wrong because inserting a pillow under the client’s knees can increase the risk of thromboembolism, which is a potential complication of cesarean birth.

Choice B is wrong because positioning the client in reverse Trendelenburg can increase the risk of maternal aspiration, which is another potential complication of cesarean birth.

Choice C is wrong because assisting the client into the lithotomy position can also compress the inferior vena cava and reduce placental blood flow. The lithotomy position is also not necessary for cesarean birth, as the baby is delivered through an incision in the abdomen and uterus.

A. Transfer a client who is receiving radiation therapy to radiology. B. Measure vital signs for a client who requires contact precautions. C. Record urine output for a client who has a suprapubic catheter. D. Plan care for a client who has dysphagia.

Correct Answer is ["B","C"]

Explanation

The correct answers are B and C.

Choice A Reason: Transferring a client who is receiving radiation therapy involves understanding the precautions and care associated with radiation, which may be beyond the training of assistive personnel (AP). Radiation therapy clients may have specific safety and transport protocols that require the expertise of licensed nursing staff.

Choice B Reason: Measuring vital signs for a client who requires contact precautions is a task that can be delegated to AP. Assistive personnel can be trained in infection control procedures and the use of personal protective equipment (PPE), making them capable of measuring vital signs while adhering to contact precautions.

Choice C Reason: Recording urine output for a client who has a suprapubic catheter can be delegated to AP. This task involves measuring and documenting a quantifiable data point, which does not require the clinical judgment of a nurse. AP can be trained to accurately measure and record urine output.

Choice D Reason: Planning care for a client who has dysphagia is a complex task that involves assessment and clinical judgment, which are responsibilities of the licensed nurse. Dysphagia can have serious complications, and care plans must be tailored to each client’s needs, requiring the expertise of a nurse.

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A nurse is assessing the skin turgor of an older adult client. In which of the following areas should the nurse lift the skin?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse in a long-term care facility is delegating care for a group of clients for the oncoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (select all that apply)

Correct Answer is ["B","C"]

Explanation

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