Which is important for the nurse to assess when inspecting the skin of a patient?
Wear gloves only if the skin appears broken or inflamed.
Ask the patient about personal skin care.
Avoid potentially embarrassing questions about rashes or scars.
Have artificial, preferably fluorescent, lighting for proper illumination of the skin.
The Correct Answer is B
A. Wear gloves only if the skin appears broken or inflamed. Gloves should be worn to protect both the patient and the nurse from infection regardless of the appearance of the skin.
B. Ask the patient about personal skin care. Understanding the patient's personal skin care practices can provide insight into potential issues and areas needing attention.
C. Avoid potentially embarrassing questions about rashes or scars. Addressing rashes or scars is crucial for proper assessment and treatment, despite potential embarrassment.
D. Have artificial, preferably fluorescent, lighting for proper illumination of the skin. Proper lighting is important, but asking about personal skin care can provide additional context and help with a thorough assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hard-milled soap: Hard-milled soaps can be less irritating than other types, but it’s more about the ingredients rather than the milling process.
B. Perfumed soap: Perfumed soaps often contain alcohol and other chemicals that can dry and irritate the skin, making pruritus worse.
C. Lotion soap: Lotion soaps often contain moisturizers and can be less drying, so they are generally recommended for dry skin.
D. Antibacterial soap: Antibacterial soaps can be harsh and drying due to the active ingredients that kill bacteria.
Correct Answer is D
Explanation
A. Monitor for signs of seizure activity: Seizure activity is not directly related to the condition described.
B. Increase the IV rate and monitor for burn shock: Increasing the IV rate could exacerbate fluid overload; burn shock is more of a concern in the initial hours post-burn.
C. Raise the foot of the bed and apply blankets. This is not relevant to addressing the issue of large urine output.
D. Assess for signs of fluid overload: After the initial fluid resuscitation phase, large urine output may indicate that fluid is being mobilized from the tissues back into the vascular system, potentially leading to fluid overload.
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