In performing a focused assessment, the practical nurse (PN) lifts the client's skin as seen in the photo. Which should the PN do next?
Assess the degree of skin elasticity.
Record palpated skin temperature.
Measure the depth of indentation.
Observe for swelling and inflammation.
The Correct Answer is A
A. Lifting the skin is a common technique used to assess skin turgor, which is the elasticity of the skin.By letting go, the nurse can observe how quickly the skin snaps back into place, indicating good or poor elasticity.
B. recording palpated temperature might be done during a focused assessment, but it wouldn't necessarily be the next step after lifting the skin.
C. measuring indentation depth might be relevant for assessing edema (swelling), but it's not the primary focus after lifting for turgor.
D. observing swelling could be assessed visually without lifting the skin, and while it's important, assessing elasticity comes first in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A preschooler who had an emergency appendectomy should be checked first. Children are at higher risk for complications due to their size and the stress of emergency surgery, so close monitoring is essential.
B. An adult with osteomyelitis post-surgery is important to monitor but is generally at lower immediate risk compared to a young child following emergency surgery.
C. A post-menopausal client with breast cancer who had a lumpectomy is also a priority, but the immediate postoperative period for a child in emergency surgery takes precedence.
D. An adolescent with type 1 diabetes who had cholecystectomy requires careful monitoring, but the child’s higher risk in the immediate postoperative phase makes them the priority.
Correct Answer is D
Explanation
A. Palpating the brachial artery before inflating the blood pressure cuff is a correct technique to locate the artery and ensure accurate blood pressure measurement.
B. Counting respirations while palpating the radial pulse is a correct technique as it minimizes the risk of the client altering their breathing pattern.
C. Asking the client to relax their arm before taking the blood pressure is an appropriate step to ensure an accurate measurement.
D. Inserting a thermometer into the sublingual pocket after the client sips water can affect the accuracy of the temperature reading, as water can alter the temperature measurement.
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