The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the priority?
a. Pressure points
b. Breath sounds
c. Bowel sounds
d. Pulse points
ANS: A
Observe pressure points such as bony prominences. The nurse continually assesses the skin for signs of ulcer development. Assessment for tissue pressure damage includes visual and tactile inspection of the skin. Assessment of pulses, breath sounds, and bowel sounds is part of a head-to-toe assessment and could influence the function of the body and ultimately skin integrity; however, this assessment is not a specific part or priority of a skin assessment.
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