A nurse is assessing for jaundice on a dark-skinned client. Which site should the nurse examine to identify jaundice on this client?
Sclera
Dorsal surface of the foot
Pinnae of the ears
Palmar surface of the hand
The Correct Answer is A
Choice A Reason:
Sclera is correct. The sclera, or the white part of the eye, is a reliable site to assess for jaundice, especially in dark-skinned individuals. Jaundice causes a yellowish discoloration of the sclera due to the accumulation of bilirubin in the blood. This yellowing is often more noticeable in the sclera than in other parts of the body.
Choice B Reason:
Dorsal surface of the foot is incorrect. The dorsal surface of the foot is not a reliable site for assessing jaundice, particularly in dark-skinned individuals. The skin on the feet may not show the yellow discoloration as clearly as the sclera.
Choice C Reason:
Pinnae of the ears is incorrect. The pinnae, or outer parts of the ears, are not typically used to assess for jaundice. The skin in this area may not show the yellow discoloration as effectively as the sclera.
Choice D Reason:
Palmar surface of the hand is incorrect. While the palms can sometimes show signs of jaundice, they are not as reliable as the sclera. The yellow discoloration may be less noticeable on the palms, especially in dark-skinned individuals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
When calculating the fluid balance for a client undergoing continuous bladder irrigation (CBI), the irrigation solution must be deducted from the total urine output. This is because the irrigation fluid is not part of the client’s actual urine production but is an additional fluid introduced into the bladder to prevent or remove blood clots and ensure catheter patency. By deducting the irrigation solution from the total urine output, the nurse can accurately determine the client’s true urine output and fluid balance.
Choice B Reason:
Subtracting the irrigation solution from the intravenous flow sheet as output is incorrect. The intravenous flow sheet is used to document fluids administered intravenously, not those introduced into the bladder. Therefore, this choice does not apply to the management of continuous bladder irrigation.
Choice C Reason:
Documenting the intake hourly in the urine output column is also incorrect. The urine output column should reflect the actual urine produced by the client, not the irrigation solution. Including the irrigation solution in this column would lead to an inaccurate representation of the client’s urine output and fluid balance.
Choice D Reason:
Adding the irrigation solution to the oral intake column is incorrect as well. The oral intake column is designated for fluids consumed orally by the client. The irrigation solution is introduced directly into the bladder and should not be recorded as oral intake.
Correct Answer is A
Explanation
Choice A Reason:
Mobilizes secretions is correct. Expectorants work by thinning and loosening the mucus in the airways, making it easier to cough up and expel. This helps clear the respiratory tract of mucus and other secretions, making the cough more productive.
Choice B Reason:
Suppresses the urge to cough is incorrect. This describes the action of antitussives, not expectorants. Antitussives work by suppressing the cough reflex, which is different from the mechanism of expectorants.
Choice C Reason:
Reduces inflammation is incorrect. While reducing inflammation can help with respiratory symptoms, it is not the primary mechanism of action for expectorants. Anti-inflammatory medications are used to reduce inflammation.
Choice D Reason:
Dries mucous membranes is incorrect. Drying mucous membranes is typically the action of antihistamines, not expectorants. Expectorants aim to increase the moisture in mucus to make it less sticky and easier to expel.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today