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 A

Explanation

A. Docusate sodium is a stool softener, and it may take 1-3 days to produce a bowel movement, so this statement reflects proper understanding.

B. Docusate is used to prevent constipation, not treat diarrhea, so this statement is incorrect.

C. Taking docusate sodium with mineral oil can increase the risk of absorption of mineral oil into the system, which is harmful, so this combination should be avoided.

D. The client should drink plenty of fluids, around 8 ounces or more, to help soften the stool.

A. The client should be taught that the goal of therapy is to have a bowel movement daily. B. The client should try to take in all of the required dietary fiber with the morning meal. C. The client should follow a high fiber diet to establish bowel regularity D. The client should take two to three 8 oz glasses of water each day.

Correct Answer is C

Explanation

A. Having a daily bowel movement may not be realistic or necessary for all clients. The goal should be regularity based on the client's usual patterns.

B. Fiber intake should be spread throughout the day, not concentrated in a single meal, to aid digestion and prevent bloating.

C. A high fiber diet is essential in managing chronic constipation as it helps increase stool bulk and promotes regular bowel movements.

D. The client should drink at least 8 glasses of water daily, not just 2-3, to aid in bowel movements and prevent constipation.

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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 is providing teaching to a client who takes opioid pain medication and has a new prescription for docusate sodium. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is preparing a teaching plan for a client who has chronic constipation secondary to irregular bowel habits. Which of the following should the nurse plan to include in the teaching?

Correct Answer is C

Explanation

Which of the following is a common risk factor for developing a urinary tract infection (UTI)?

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning?

A nurse is teaching a client about foods and beverages that can cause diarrhea. Which of the following should the nurse include in the teaching?

Which patient is most at risk for diarrhea?

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?

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

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