When you receive the shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate?

Redo the initial assessment and document current findings

Perform and document a focused assessment of skin integrity

Correct the initial assessment form

Conduct and document an emergency assessment

Answer and Explanation

The Correct Answer is B

A. Redo the initial assessment and document current findings:

This option suggests repeating the entire initial assessment. While reassessment is important, redoing the entire initial assessment may not be necessary. Instead, a focused assessment on the specific area of concern (skin integrity) is more appropriate.

B. Perform and document a focused assessment of skin integrity:

This is the recommended choice. If unexpected findings are observed during care, such as reddened areas over bony prominences, it is important to conduct a focused assessment on the skin to identify any issues and document the findings accurately.

C. Correct the initial assessment form:

Simply correcting the initial assessment form may not address the immediate need for assessing and addressing the reddened areas. It is more crucial to perform a focused assessment on the skin.

D. Conduct and document an emergency assessment:

Reddened areas over bony prominences may not necessarily indicate an emergency. However, addressing the issue promptly is important. A focused assessment would be more appropriate than conducting a full emergency assessment.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Change the plan of care to provide different pain relief interventions:

While changing the plan of care may be necessary, it should be based on a thorough reassessment. Simply changing the plan without understanding the reasons for inadequate pain relief may not lead to effective outcomes.

B. Reassess the client to determine the reasons for inadequate pain relief.

Reassessment is a crucial step in the nursing process, especially when the desired outcomes are not achieved. By reassessing the client, the nurse can identify any factors contributing to the inadequate pain relief. This might include reevaluating the effectiveness of the current pain relief interventions, ensuring proper administration of medications, considering changes in the client's condition, or exploring any new factors affecting pain.

C. Teach the client about the plan of care for managing his pain:

Teaching is an important aspect, but in this case, reassessment takes precedence. Once the reasons for inadequate pain relief are determined, teaching can be tailored to address specific needs.

D. Wait to see whether the pain lessens during the next 24 hours:

If the pain is not adequately controlled, waiting for another 24 hours without action may prolong the client's discomfort and delay appropriate interventions. Reassessment and prompt adjustments to the plan of care are crucial for effective pain management.

A. Comatose B. Awake and alert C. Lethargic D. Stuporous

Correct Answer is C

Explanation

A. Comatose:

Coma refers to a state of deep unconsciousness where the individual is unresponsive to stimuli, including pain or external stimulation. In the scenario described, the patient is not comatose because they can be awakened by gentle shaking and calling their name.

B. Awake and alert:

This term describes a state of full alertness and responsiveness to the environment. The patient in the scenario is not fully awake and alert since they appear drowsy most of the time and require external stimuli to be awakened.

C. Lethargic:

Lethargy is characterized by drowsiness, reduced alertness, and a sluggish response to stimuli. In the scenario, the patient is described as drowsy most of the time but can be awakened by gentle shaking and calling their name. This aligns with the characteristics of lethargy.

D. Stuporous:

Stupor is a state of reduced responsiveness where the individual can be aroused only by vigorous or painful stimuli. The patient in the scenario does not fit the criteria for stupor as they can be awakened by gentle shaking and calling their name.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

When you receive the shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

A nurse is taking a blood pressure measurement to assess for orthostatic hypotension in a client. Which signs and symptoms will the nurse assess related to this condition? (Select all that apply.)

The nurse is surprised to detect an elevated temperature (102 °F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do?

Ordered: Hydroxyzine (Vistaril) 35 mg IM stat Available: Hydroxyzine (Vistaril) 50 mg/mL Administer: ____ ml

A nurse is assessing a client’s radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

A nurse is orienting a newly licensed nurse about documentation of a client’s information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment, what finding would the nurse expect?

Ordered: Potassium chloride (K-Dur) 60 mEq Available: Potassium chloride (K-Dur) 20 mEq/15 mL Administer: _____mL

A nursing student is preforming a head-to-toe assessment on his patient with a history of mitral regurgitation. Instead of hearing normal heart sounds the student hears a murmur. Which of the following best describes the sound of a heart murmur?