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

A. Inspiratory stridor

Inspiratory stridor is a high-pitched, musical sound heard during inspiration and is typically caused by turbulent airflow due to partial obstruction of the upper airway. It is commonly associated with conditions such as croup, epiglottitis, or anaphylaxis. While respiratory distress may occur in a pneumothorax, inspiratory stridor specifically suggests an upper airway obstruction rather than a pneumothorax.

B. Expiratory wheeze

Expiratory wheeze is a high-pitched, musical sound heard during expiration and is typically associated with conditions such as asthma, chronic obstructive pulmonary disease (COPD), or bronchiolitis. Wheezing occurs due to narrowing of the airways, leading to turbulent airflow during expiration. While a pneumothorax can cause respiratory distress, it is not typically associated with wheezing.

C. Absence of breath sounds

The absence of breath sounds over a particular area of the chest can indicate a pneumothorax. In a pneumothorax, air accumulates in the pleural space, causing partial or complete collapse of the lung and preventing it from making contact with the chest wall. This absence of breath sounds over the affected area is a classic finding in a pneumothorax and is crucial for its detection.

D. Coarse crackles

Coarse crackles are discontinuous, bubbling or popping sounds heard during inspiration and may be indicative of conditions such as pneumonia, pulmonary edema, or bronchiectasis. These crackles are typically heard when there is fluid or mucus in the airways. While a pneumothorax can cause respiratory distress, it does not typically produce crackles on auscultation.

A. Saving the sputum specimen in a clean container.

While it is important to collect the sputum specimen in a clean, sterile container, simply saving the specimen in a clean container is not sufficient. The nurse needs to actively collect the sputum specimen from the client using proper technique to ensure that it is not contaminated and is suitable for laboratory analysis.

B. Collecting the sputum specimen after a meal.

Collecting a sputum specimen after a meal is not recommended, as it can increase the likelihood of contamination with food particles. It's preferable to collect the specimen before meals or at least 1-2 hours after eating to minimize the risk of contamination and ensure the integrity of the specimen.

C. Rinse the client's mouth before collecting the specimen.

When obtaining a sputum specimen from a client, it's important for the nurse to plan to rinse the client's mouth before collecting the specimen. Rinsing the mouth with water helps to clear any food particles or debris from the oral cavity, ensuring that the sputum sample collected is not contaminated with saliva or food particles. This improves the quality and accuracy of the specimen for laboratory analysis.

D. Obtaining the specimen from the client in the evening.

The timing of specimen collection is not necessarily restricted to the evening. The timing may vary depending on the client's condition and the healthcare provider's orders. It's important to follow the healthcare provider's instructions regarding the timing of specimen collection, which may be based on factors such as the client's symptoms and the diagnostic requirements.