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 ["B","E"]
Explanation
A. Urinalysis is not directly related to evaluating the effectiveness of an antibiotic for a respiratory tract infection.
B. Sputum culture and sensitivity are crucial in determining the specific bacteria causing the infection and assessing the antibiotic’s effectiveness in eradicating the pathogen.
C. Prothrombin time is related to blood clotting and is not relevant to monitoring the effectiveness of an antibiotic for a respiratory infection.
D. Serum potassium is important for monitoring electrolyte balance but does not directly evaluate the effectiveness of an antibiotic.
E. White blood cell count is a key indicator of infection and inflammation; a decrease in WBC count suggests that the antibiotic is effectively combating the infection.
F. Capillary glucose monitoring is more relevant to diabetic management and is not used to evaluate antibiotic effectiveness.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
Respiratory acidosis
The laboratory results show a pH of 7.31, which is below the normal range of 7.35-7.45, indicating acidosis. Additionally, the PaCO2 is elevated at 51 mmHg, which is above the normal range of 35-45 mmHg, pointing towards a respiratory cause of the acidosis.
Carbon dioxide retention
During the submersion, the child likely experienced impaired ventilation, leading to hypoventilation and subsequent retention of carbon dioxide. This retention of CO2 contributes to respiratory acidosis.
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