A nurse is assessing a client who has asthma and signs of central cyanosis. Which of the following is a reliable indicator of cyanosis?

Oral mucosa

Tip of the nose

Ear lobes

Eye lids

Answer and Explanation

The Correct Answer is A

A. Oral mucosa:

The oral mucosa, including the inside of the mouth, tongue, and lips, is a reliable indicator of cyanosis. Cyanosis appears as a bluish discoloration of these tissues due to decreased oxygen saturation in the arterial blood. Assessing the oral mucosa is an essential component of clinical examination, especially in patients with respiratory conditions like asthma, as it provides valuable information about oxygenation status.

B. Tip of the nose:

While the tip of the nose may exhibit cyanosis in some cases, it is not considered as reliable of an indicator as the oral mucosa. The nasal tip is more susceptible to external factors such as cold temperatures or poor circulation, which can cause temporary discoloration. Therefore, it may not always accurately reflect the oxygenation status of the patient compared to the oral mucosa.

C. Ear lobes:

Cyanosis may be observed in the ear lobes in cases of severe hypoxemia, but it is not as reliable of an indicator as the oral mucosa. The ear lobes are less commonly assessed for cyanosis compared to other areas such as the lips, nail beds, or oral mucosa. While cyanosis may be present in the ear lobes, it is not typically the primary site assessed for oxygenation status.

D. Eyelids:

Cyanosis is not typically observed in the eyelids and is not considered a reliable indicator of hypoxemia. The eyelids are not commonly assessed for cyanosis during clinical examinations. While the conjunctiva (the lining inside the eyelids) may appear pale in cases of severe anemia, it is not a specific sign of hypoxemia. Assessment of the oral mucosa, lips, and nail beds is preferred for evaluating oxygenation status in patients with respiratory conditions like asthma.

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Correct Answer is B

Explanation

A. Facial flushing

Facial flushing is not typically associated with atelectasis. Instead, it may occur in conditions such as oxygen toxicity or fever.

B. Increasing dyspnea

Atelectasis is a condition characterized by the collapse or partial collapse of a portion of the lung. Common findings in a client with atelectasis include increasing dyspnea (shortness of breath) due to impaired gas exchange and reduced lung function. As the affected lung tissue collapses, ventilation and oxygenation are compromised, leading to difficulty breathing.

C. Decreasing respiratory rate

A decreasing respiratory rate is not typically observed in a client with atelectasis. Instead, respiratory rate may increase as the body attempts to compensate for the impaired gas exchange and oxygenation resulting from lung collapse.

D. Dry cough

While coughing is a common symptom of atelectasis, it is typically associated with a productive cough rather than a dry cough. A dry cough is more commonly associated with conditions such as viral respiratory infections or allergic reactions. In atelectasis, the cough may be productive as the body attempts to clear mucus or other secretions from the affected airways.

A. The patient's Spo2 is 97% on 2L NC B. The patient appears comfortable C. The patient is coughing up copious white sputum D. The patient is able to move out of bed without difficulty

Correct Answer is A

Explanation

A. The patient's Spo2 is 97% on 2L NC:

This assessment finding indicates that the patient's oxygen saturation level (SpO2) is 97% while receiving 2 liters per minute of oxygen via nasal cannula. Oxygen saturation is a measure of the percentage of hemoglobin saturated with oxygen in the blood. A SpO2 level of 97% suggests adequate oxygenation, which is essential for effective gas exchange. Therefore, if the patient's SpO2 is within the target range on the prescribed oxygen therapy, it indicates that the interventions aimed at improving gas exchange have been effective.

B. The patient appears comfortable:

While patient comfort is important, it is not a direct indicator of effective gas exchange. A patient may appear comfortable for various reasons, such as pain relief, proper positioning, or emotional support, but this does not necessarily reflect improved gas exchange. Therefore, while comfort is an important aspect of nursing care, it is not specifically indicative of the effectiveness of interventions for impaired gas exchange.

C. The patient is coughing up copious white sputum:

The presence of copious white sputum does not directly indicate improved gas exchange. White sputum may suggest various conditions, such as respiratory tract infections or inflammation, but it does not provide direct information about gas exchange efficiency. Effective gas exchange involves the exchange of oxygen and carbon dioxide at the alveolar-capillary membrane, which cannot be assessed solely based on sputum production.

D. The patient is able to move out of bed without difficulty:

The ability to move out of bed without difficulty may indicate improved overall physical function or mobility, but it does not specifically reflect improved gas exchange. Gas exchange primarily involves the transfer of oxygen from the alveoli into the bloodstream and the removal of carbon dioxide from the bloodstream into the alveoli for exhalation. While improved gas exchange may lead to enhanced physical endurance and reduced dyspnea, the ability to move out of bed without difficulty is not a direct measure of gas exchange efficiency.

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