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 D

Explanation

A. Aortic and Mitral: The mitral valve is associated with the S1 sound, not S2. S2 occurs when the semilunar valves (aortic and pulmonic) close.

B. Mitral and Pulmonic: The mitral valve closure is heard in S1, while the pulmonic valve closure is part of S2. However, the mitral valve is not involved in S2.

C. Mitral and Tricuspid: The mitral and tricuspid valves close during S1, not S2. These valves are atrioventricular (AV) valves, not semilunar valves.

D. Aortic and Pulmonic: The second heart sound (S2) is produced by the closure of the aortic and pulmonic valves at the beginning of diastole. This marks the end of systole.

A. Initiate a peripheral IV B. Administer another nitroglycerin tablet C. Obtain an ECG/EKG D. Call the Rapid Response Team

Correct Answer is C

Explanation

A. Initiate a peripheral IV: While an IV line is useful for medication administration, the patient’s pain has significantly improved with nitroglycerin. An IV may be necessary later, but it is not the next step in this scenario.

B. Administer another nitroglycerin tablet: Nitroglycerin can be repeated every 5 minutes up to 3 doses if chest pain persists or does not decrease significantly. Since the pain has improved (from 6 to 2), additional nitroglycerin is unnecessary.

C. Obtain an ECG/EKG: Even though the pain improved, unstable angina can progress to myocardial infarction. An ECG helps evaluate for ischemic changes and ensures the pain is truly resolving.

D. Call the Rapid Response Team (RRT): RRT should be called for worsening chest pain, unresponsiveness, or hemodynamic instability. Since the pain has improved, calling RRT is unnecessary.

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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

A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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