Basic Care and Comfort Practice Question

Question

The nurse is caring for a client with impaired sensation and is focused on skin hygiene scenario 8. Which nursing action is most appropriate?

Answer choices

1. A. Delay assessment until the next scheduled round if the client is not calling for help.
2. B. Delegate the clinical assessment and nursing judgment to assistive personnel.
3. C. Document the concern without notifying the appropriate provider or care team member when escalation is needed.
4. D. Keep skin clean and dry while protecting fragile areas from breakdown.

Correct Answer

D. Keep skin clean and dry while protecting fragile areas from breakdown.

Explanation

The priority action for skin hygiene is to keep skin clean and dry while protecting fragile areas from breakdown. NCLEX-style prioritization favors safety, assessment, appropriate delegation, timely escalation, and client-centered teaching.

Question details

• Difficulty: hard
• Domain: Basic Care and Comfort
• Objective: skin hygiene

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