The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? Select all that apply.

Check skin for unusual bruising.

Palpate mucus membranes for cracks.

Monitor color of nailbeds.

Assess skin folds of perineal area.

Observe skin under the breasts.

Answer and Explanation

Correct Answer : D,E

A. Check skin for unusual bruising is not directly related to the client's diaphoretic condition. While bruising may be relevant in some cases, it is not the priority in this scenario, where the focus is on managing moisture and skin integrity.

B. Palpate mucus membranes for cracks is not as relevant in this situation. Cracks in the mucus membranes could indicate dehydration or other issues, but the primary concern for a diaphoretic client is skin breakdown due to moisture.

C. Monitor color of nailbeds is important in general assessment, but it is not directly related to the client's diaphoretic condition. Nailbed color may indicate circulation issues, but it is not a primary concern for this scenario.

D. Assess skin folds of perineal area is important because moisture from perspiration can accumulate in skin folds, increasing the risk for skin breakdown or infection, especially in overweight clients.

E. Observe skin under the breasts is also critical. The skin under the breasts is prone to moisture buildup, which can lead to irritation, fungal infections, or skin breakdown in overweight clients. Regular assessment of this area is necessary to prevent complications.

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Correct Answer is D

Explanation

A. Identify effective pain relief measures is important but not the first step in assessing pain quality. The nurse must first assess the pain itself before determining what interventions are effective.

B. Provide a numeric pain scale is commonly used to assess the intensity of pain, but it does not address the quality of pain. The numeric scale helps measure the severity, but it does not capture how the pain feels.

C. Observe body language and movement can provide clues about pain but does not give a comprehensive understanding of the pain's quality. While useful for assessing nonverbal clients, this approach alone does not provide detailed information about the pain experience.
D. Ask the client to describe the pain is the best approach for assessing the quality of pain. By asking the client to describe the pain, the nurse can gather information about its characteristics, such as sharp, dull, burning, or aching, which provides insight into the nature of the pain and helps guide appropriate interventions.

A. Dons sterile gloves when caring for clients with HIV. B. Uses sterile gloves when handling body fluids. C. Keeps a pair of gloves in uniform pocket. D. Puts on new gloves when entering a client's room.

Correct Answer is B

Explanation

A. Dons sterile gloves when caring for clients with HIV is incorrect. HIV is transmitted through specific body fluids such as blood, semen, and vaginal fluids, but sterile gloves are not required for routine care unless there is a risk of exposure to these fluids. Standard precautions are used for all clients, regardless of their diagnosis.

B. Uses sterile gloves when handling body fluids is correct. Sterile gloves are used in situations where there is a high risk of contamination, such as when handling body fluids that may contain infectious agents, or during invasive procedures.

C. Keeps a pair of gloves in uniform pocket is incorrect. Gloves should not be stored in pockets as this may compromise their sterility or cleanliness. Gloves should be stored in a clean, dry place.

D. Puts on new gloves when entering a client's room is incorrect. Gloves should be worn when necessary, such as when there is a risk of contact with body fluids or contaminated surfaces. They should not be put on automatically without assessing the situation.

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The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To assess the quality of an adult client's pain, which approach should the nurse use?

Correct Answer is D

Explanation

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

Correct Answer is B

Explanation

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