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.

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Correct Answer is C

Explanation

A. Skin fold:

This may not be the best choice in this situation because the skin fold might not provide an accurate reading, especially if the hands are edematous.

B. Toe:

While the toe is a common site for pulse oximetry, in a patient with bilateral lower leg amputations, it might not be the most practical option. The nurse might face challenges in securing the pulse oximeter probe on the toe, and the accuracy of the reading could be affected.

C. Earlobe:

This is often a suitable alternative site for pulse oximetry when peripheral perfusion is compromised in the extremities. In this case, with bilateral lower leg amputations and edematous hands, applying the pulse oximeter probe to the earlobe is a good choice.

D. Finger:

In a patient with edematous hands, the finger might not be the best choice as the edema could affect the accuracy of the measurement. Additionally, if the patient has lower leg amputations, using the earlobe or another alternative site may be more appropriate.

A. Validate the finding B. Document the finding C. Inform the surgeon D. Inform the charge nurse

Correct Answer is A

Explanation

A. Validate the finding:

Validating the finding involves rechecking the patient's temperature using a different thermometer or method to confirm the accuracy of the initial measurement. This step is crucial to rule out any potential errors or issues with the measurement.

B. Document the finding:

Once the finding has been validated and confirmed, the nurse should document the elevated temperature accurately in the patient's medical record. Documentation is essential for communication among the healthcare team and for tracking changes in the patient's condition over time.

C. Inform the surgeon:

If the elevated temperature is confirmed and the patient is scheduled for surgery, it is important to inform the surgeon promptly. The surgeon needs to be aware of any changes in the patient's health status that may impact the decision to proceed with the scheduled surgery.

D. Inform the charge nurse:

Informing the charge nurse may be appropriate, especially if there are specific protocols or procedures in place within the healthcare facility for addressing unexpected changes in a patient's condition. The charge nurse can provide guidance and coordinate appropriate actions.

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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

A nurse is preparing to measure a client’s level of oxygen saturation on a patient who has had a bilateral lower leg amputation. He noticed the patient’s hands are very edematous. The nurse should apply the pulse oximeter probe to which of the following locations?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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