A nurse is performing a skin assessment on a client who has dark skin.

Which of the following locations on the client’s body should the nurse observe to assess for cyanosis?

Area of trauma.

Sacrum.

Shoulders.

Palms of the hands.

Answer and Explanation

The Correct Answer is D

Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. It is more difficult to detect in people who have dark skin, so the nurse should look for cyanosis in areas where the skin is thinner and the blood supply is richer, such as the palms of the hands, the lips, the gums, and around the eyes.
These areas are less affected by melanin, the pigment that gives skin its color.

Choice A is wrong because an area of trauma may have bruising or inflammation that can mask cyanosis.
Choice B is wrong because the sacrum is not a good site to assess for cyanosis in any skin tone, as it is prone to pressure ulcers and poor circulation.
Choice C is wrong because the shoulders are not a mucous membrane and may have more melanin than other areas of the body.

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Correct Answer is B,D,A,C

Explanation

B. Review the skill level and qualifications of each AP.

Before delegating tasks, the nurse should assess the skill level and qualifications of each AP to ensure they have the necessary knowledge and training to perform the assigned tasks safely and effectively.

D. Communicate appropriate tasks to the APs with specific expectations.

The nurse should clearly communicate the tasks to be delegated to each AP. This includes providing specific instructions, expectations, and any necessary information to ensure the APs understand what is expected of them and can perform the tasks correctly.

A. Monitor progress of task completion with each AP.

Once the tasks are assigned, the nurse should periodically check in with each AP to monitor the progress of task completion. This allows the nurse to provide support, answer questions, and ensure that tasks are being performed as expected.

C. Evaluate the APs' performance of each task.

After the tasks are completed, the nurse should evaluate the APs' performance of each task. This evaluation helps identify any areas for improvement, additional training needs, and overall competency of the APs.

Delegating tasks to assistive personnel is an essential aspect of nursing practice. Following this sequence of steps helps ensure that tasks are delegated appropriately and that the care provided is safe, efficient, and aligned with the APs' capabilities. Regular communication and feedback are essential to effective task delegation and teamwork within the healthcare setting.

A. Drink four 240 mL (8 oz) glasses of water each day. B. Void every 5 to 6 hr during the day. C. Wear loose-fitting underwear. D. Take a bubble bath after intercourse.

Correct Answer is C

Explanation

This is because tight-fitting underwear can trap moisture and create a favorable environment for bacterial growth, which can increase the risk of urinary tract infections (UTIs) . Loose-fitting underwear can allow air circulation and prevent moisture accumulation .

Choice A is wrong because drinking four 240 mL (8 oz) glasses of water each day is not enough to prevent UTIs. The recommended amount of water intake for adults is about 2 to 3 liters per day . Drinking enough water can help flush out bacteria from the urinary tract and prevent them from adhering to the bladder wall .

Choice B is wrong because voiding every 5 to 6 hours during the day is too infrequent and can increase the risk of UTIs. The nurse should advise the client to void every 2 to 3 hours during the day. This can help prevent urinary stasis and bacterial multiplication in the bladder .

Choice D is wrong because taking a bubble bath after intercourse can increase the risk of UTIs. The nurse should instruct the client to avoid bubble baths, vaginal douches, or sprays, as they can irritate the urethra and introduce bacteria into the urinary tract . The nurse should also advise the client to empty the bladder before and after sexual intercourse, as this can help remove bacteria that may have entered the urethra during sexual activity .

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A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client’s body should the nurse observe to assess for cyanosis?

Nursing Test Bank

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A nurse is performing a skin assessment on a client who has dark skin.

Which of the following locations on the client’s body should the nurse observe to assess for cyanosis?