What are the functions of the skin? (Select All that Apply.)

Temperature Regulation

Protection

Sensation

Vitamin D Production

Vitamin C Production

Answer and Explanation

Correct Answer : A,B,C,D

Choice A rationale: The skin helps regulate body temperature by sweating and dilation or constriction of blood vessels.
Choice B rationale: The skin acts as a barrier, protecting the body from external threats such as pathogens and physical injury.
Choice C rationale: The skin is rich in sensory receptors, allowing for the perception of touch, pressure, pain, and temperature.
Choice D rationale: The skin plays a role in the production of vitamin D when exposed to sunlight.
Choice E rationale: Vitamin C production is not a function of the skin; vitamin C is obtained through diet.

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Correct Answer is A

Explanation

Choice A rationale: Performing hand hygiene before any wound care procedure is essential to prevent infection and maintain aseptic technique.
Choice B rationale: Assessing the condition of the visible wound bed is an important step but not the first action. Hand hygiene should precede any assessment or intervention.
Choice C rationale: Measuring the width of the wound with a disposable ruler is part of the wound measurement process but should follow hand hygiene.
Choice D rationale: Inserting a swab into the wound at 90 degrees is not the first step. Hand hygiene and assessment should precede any invasive procedures.

A. A physician’s order is needed B. Use a lubricated index finger to break up some of the mass and remove it C. Sterile gloves should be used for the procedure D. The mass should be removed as a whole E. The patient should be in the side lying position.

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale: A physician's order is typically required for a digital removal of a fecal impaction.
Choice B rationale: Using a lubricated index finger to break up some of the mass and remove it is a correct step in the procedure.
Choice C rationale: Sterile gloves are not required for a digital removal of a fecal impaction. Clean gloves are generally sufficient.
Choice D rationale: The mass may need to be broken up into smaller pieces for removal, rather than being removed as a whole.
Choice E rationale: The patient is usually positioned in a side-lying position for comfort and accessibility during the procedure.

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What are the functions of the skin? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When measuring the size, depth, and wound tunneling of a client's stage 4 pressure injury, what action should the nurse perform first?

Correct Answer is A

Explanation

A nurse is preparing to complete a digital removal of a fecal impaction. What statement indicates the nurse has an appropriate understanding of this procedure? (Select All that Apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as:

A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?

During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing:

A wound care nurse has been consulted on a patient with multiple pressure wounds. The nurse comes across this heal wound. How should she document the following wound?

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs additional 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?

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement?