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

Pressure points

Breath sounds

Pulse points

Bowel sounds

Answer and Explanation

The Correct Answer is A

A. Pressure points are critical to assess when evaluating skin integrity, particularly in patients who are immobile or bedridden, as these areas are at high risk for pressure ulcers.

B. Breath sounds are important but are not the priority in assessing skin integrity.

C. Pulse points assess circulation, but they are not directly related to skin integrity.

D. Bowel sounds are relevant for digestive assessments, not for skin integrity.

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Correct Answer is D

Explanation

A. A small amount of red drainage is expected immediately after surgery.

B. A shiny, moist stoma indicates healthy tissue and is a normal finding.

C. A rosebud-like appearance of the stoma is expected for a newly created colostomy.

D. A purplish-colored stoma is a sign of compromised circulation and possible necrosis, which requires immediate medical attention.

A. Blood in urine B. Cloudy urine C. Leakage of urine D. Dark-colored urine

Correct Answer is C

Explanation

A. Blood in the urine (hematuria) is not typically associated with urinary retention but can indicate other conditions such as infection or trauma.

B. Cloudy urine may indicate infection but is not a direct sign of urinary retention.

C. Leakage of urine, or overflow incontinence, occurs when the bladder becomes overly full due to retention and releases small amounts of urine involuntarily.

D. Dark-colored urine typically indicates dehydration, which is not a specific sign of urinary retention.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is assessing a client who has urinary retention. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is planning care for a client who is confined to bed. Which of the following actions should the nurse include in the plan?

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Which patient is most at risk for diarrhea?

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times?

A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?