The nurse is assessing skin turgor. Which technique will the ...

[bio_gurl]

The nurse is assessing skin turgor. Which technique will the nurse use?
 
  a. Press lightly on the forearm.
  b. Press lightly on the fingertips.
  c. Grasp a fold of skin on the sternal area.
  d. Grasp a fold of skin on the back of the hand.

Question 2

An older-adult patient is taking aminoglycoside for a severe infection. Which assessment is the priority?
 
  a. Eyes
  b. Ears
  c. Skin
  d. Reflexes

[Pamela.irrgang@yahoo.com]

Answer to Question 1

ANS: C
To assess skin turgor, grasp a fold of skin on the back of the forearm or sternal area with the fingertips and release. Since the skin on the back of the hand is normally loose and thin, turgor is not reliably assessed at that site. Pressing lightly on the forearm can be used to assess for pitting edema or pain or sense of touch. Pressing lightly on the fingertips and observing nail color is assessing capillary refill.

Answer to Question 2

ANS: B
Older adults are especially at risk for hearing loss caused by ototoxicity (injury to auditory nerve) resulting from high maintenance doses of antibiotics (e.g., aminoglycosides). While eyes and skin are important, they are not the priority. Reflexes are expected to be diminished in older adults.

[bio_gurl]

TYSM

[juliaf]

Gracias!