You have received a report and are providing skin care for the following patients. Which patient do you want to assess first?

A 58-year-old patient with uncontrolled diabetes mellitus type two and intact skin.

A 48-year-old patient with poor nutrition, warmth and edema to the coccyx.

An 82-year-old patient with a surgical incision and approximated wound edges.

A 69 year old patient with a colostomy and blanchable erythema to the sacrum.

Answer and Explanation

The Correct Answer is B

A. 58-year-old patient with uncontrolled diabetes mellitus type 2 and intact skin: While diabetes increases the risk of delayed wound healing and infection, intact skin is not an immediate concern.

B. 48-year-old patient with poor nutrition, warmth, and edema to the coccyx: Warmth and edema at a pressure site may indicate the beginning of a pressure injury or infection (e.g., cellulitis). Poor nutrition further increases the risk of skin breakdown and impaired healing, making this patient the priority for assessment.

C. 82-year-old patient with a surgical incision and approximated wound edges: A well-approximated surgical incision suggests healing is progressing normally, making this patient lower priority.

D. 69-year-old patient with a colostomy and blanchable erythema to the sacrum: Blanchable erythema is an early sign of pressure injury, but it is less concerning than warmth and edema, which suggest possible infection or worsening tissue damage.

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Correct Answer is C

Explanation

A. Check the patient's urinalysis. While a urinalysis may provide useful information (e.g., infection, kidney function), it does not address the immediate concern—significantly decreased urine output despite adequate intake. The priority is to determine urinary retention first.

B. Notify the provider of the patient's pain 7/10. While pain management is important, the more critical issue is the drastically low urine output (150mL in 12 hours), which could indicate acute urinary retention or renal dysfunction. Addressing the urinary issue should come first.

C. Perform a bladder scan. The low urine output (150mL in 12 hours) despite sufficient intake (2150mL) suggests potential urinary retention. A bladder scan is the quickest and least invasive way to determine if the patient has a full bladder that needs intervention (e.g., catheterization). This is the priority before further testing or notifying the provider.

D. Assess the daily weight. Daily weight monitoring is helpful for fluid status assessment, especially in cases of heart failure or kidney disease, but it is not the most immediate priority. The primary concern is whether the patient has urinary retention, which requires urgent evaluation.

A. Powered stand assist B. Cane C. Gait belt D. Four wheel walker

Correct Answer is C

Explanation

A. Powered stand assist: Powered stand assist devices are used for clients who cannot bear weight independently, not for balance issues during ambulation.

B. Cane: A cane provides minimal support and is best for clients with mild weakness, not for those with frequent balance loss.

C. Gait belt: A gait belt provides stability and support while allowing the nurse to assist the client safely if they begin to lose balance.

D. Four-wheel walker: A four-wheel walker rolls easily, which may increase fall risk in a client with balance issues. A standard walker (without wheels) would be safer in some cases.

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Stoma Assessment	Stoma is protruding 2cm, is red and moist. Peristomal area is clean and intact.
Output	Liquid stool that is malodorous. Gas present in the appliance.
General Status	Patient is avoiding looking at the ileostomy during care.
Laboratory Data	Potassium 3.6 mEq/L (normal 3.5 to 5 mEq/L) Sodium 137 mEq/L (normal 135 to 145 mEq/L) Creatinine 0.9 mg/dL (normal 0.6 to 1.2 mg/dL)

You have received a report and are providing skin care for the following patients. Which patient do you want to assess first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is assisting an older adult client who sometimes loses their balance while walking. Which of the following devices is most important for the nurse to use when helping the client ambulate?

Correct Answer is C

Explanation

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