The nurse is completing an assessment of the patient's skin integrity. Which assessment is the priority?

Pressure points

Pulse points

Breath sounds

Bowel sounds

Answer and Explanation

The Correct Answer is A

A. Pressure points: Pressure points (e.g., sacrum, heels, elbows, shoulders, hips) are at the highest risk for breakdown, ulcers, and impaired circulation. This makes them the priority assessment for skin integrity.

B. Pulse points: While checking pulses is important for circulatory assessment, it is not directly related to skin integrity assessment.

C. Breath sounds: Breath sounds assess respiratory function and are not a direct indicator of skin integrity.

D. Bowel sounds: Bowel sounds assess gastrointestinal function and are not relevant in a skin integrity assessment.

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Correct Answer is B

Explanation

A. Pleural effusion: A pleural effusion is the accumulation of fluid in the pleural space and is not directly related to atelectasis. Atelectasis is alveolar collapse and does not cause fluid buildup.

B. Hypoxemia: Atelectasis impairs gas exchange, leading to decreased oxygen levels (hypoxemia) due to collapsed alveoli. This is a hallmark finding.

C. Dysphagia: Dysphagia (difficulty swallowing) is not a direct symptom of atelectasis. It may be seen in stroke or esophageal disorders.

D. Apnea: Apnea (cessation of breathing) is not a typical sign of atelectasis. Atelectasis causes shallow breathing, dyspnea, and hypoxia rather than complete cessation.

A. Hold the hands higher than the elbows. B. Rub hands and arms to dry. C. Apply 4 to 5 mL of liquid soap to the hands. D. Adjust the water temperature to feel hot.

Correct Answer is C

Explanation

A. Hold the hands higher than the elbows. Hands should be held lower than the elbows to allow water to flow from the fingertips downward, preventing contamination of clean areas by dirty water.

B. Rub hands and arms to dry. Hands should be dried by patting rather than rubbing to prevent skin irritation. Also, drying should focus on the hands first, then the wrists, and then the forearms to avoid recontamination.

C. Apply 4 to 5 mL of liquid soap to the hands. The recommended amount of liquid soap is 3 to 5 mL to effectively remove microorganisms. Using too little may not clean adequately, and using too much can make rinsing difficult.

D. Adjust the water temperature to feel hot. Water should be warm, not hot, to prevent skin irritation and dryness. Hot water can damage the skin’s natural protective barrier, increasing susceptibility to infection.

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The nurse is completing an assessment of the patient's skin integrity. Which assessment is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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