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. Taking the client to the toilet immediately before a meal does not correlate with the natural timing of defecation.

B. Abdominal cramping may indicate constipation or other issues, but waiting for cramping is not part of bowel training.

C. Taking the client to the toilet every 2 hours may not align with the client’s natural bowel habits.

D. The goal of bowel training is to help the client recognize and respond to the urge to defecate, promoting regular bowel habits and reducing incontinence.

A. Drinking plenty of water B. Maintaining good personal hygiene C. Having a unity catheter D. Frequent handwashing

Correct Answer is C

Explanation

Rationale:

A. Drinking plenty of water helps to flush bacteria from the urinary tract, reducing the risk of a UTI.

B. Good personal hygiene reduces the risk of UTIs by preventing bacterial contamination.

C. Urinary catheters provide a direct pathway for bacteria to enter the bladder, increasing the risk of UTIs.

D. Frequent handwashing is a preventive measure but not directly related to the development of UTIs.

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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 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?

Correct Answer is D

Explanation

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

Correct Answer is C

Explanation

A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement?

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 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 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?

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes a wide separation of the wound edges with light serosanguineous drainage. Which of the following actions should the nurse perform first?

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?

A nurse is teaching a client who has urinary incontinence about avoiding foods and beverages that can cause bladder irritation. The nurse should include that which of the following foods and beverages is a bladder irritant?