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 C

Explanation

A. Select upper arm as the injection site is incorrect. While the upper arm can be an appropriate site for an intradermal injection, the most common site for ID injections is the inner forearm. The choice of site depends on the procedure and provider's preferences.

B. Massage the site gently after injection is incorrect. Massaging the site after an intradermal injection can disrupt the injection, causing the medication to be dispersed under the skin rather than remaining in the dermis.

C. Ensure bevel of the needle is pointing up is the correct action. For intradermal injections, the bevel of the needle should be facing upward to ensure that the medication is injected just beneath the skin, creating a visible wheal.

D. Hold the syringe perpendicular to the skin is incorrect. For intradermal injections, the needle should be inserted at a 5-15 degree angle to the skin, not perpendicular.

A. Irrigate the nasogastric tube with water. B. Elevate the head of bed 45 degrees. C. Review the advanced directive document. D. Perform oropharyngeal suctioning.

Correct Answer is D

Explanation

A. Irrigate the nasogastric tube with water may be necessary if the tube is clogged, but it does not address the immediate concern of the client choking. The priority is ensuring the client’s airway is clear.

B. Elevate the head of bed 45 degrees is a useful intervention for reducing aspiration risk, but it does not address the immediate need to clear the airway when the client is choking. Elevating the head of the bed could be helpful after the airway is cleared.

C. Review the advanced directive document is important for understanding the client’s wishes, but the immediate priority is addressing the choking. The nurse should focus on clearing the airway first, then review the advanced directive as appropriate.

D. Perform oropharyngeal suctioning is the most appropriate action. The client is vomiting and choking, which suggests a risk of airway obstruction. Oropharyngeal suctioning will help clear the airway and prevent aspiration, which is the priority in this 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

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

Correct Answer is C

Explanation

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

Correct Answer is D

Explanation

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