A nurse is performing a skin assessment on a client who has dark skin.
Which of the following techniques should the nurse use to detect cyanosis in this client?
Inspect the nail beds and lips for a bluish hue.
Palpate the skin for warmth and moisture.
Compare the skin color with a standardized color chart.
Observe the skin for pallor or ashiness.
The Correct Answer is A
Inspect the nail beds and lips for a bluish hue.
Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. In clients who have dark skin, cyanosis may be difficult to detect by visual inspection of the skin alone. The nurse should inspect the nail beds and lips for a bluish hue, as these areas are more sensitive to changes in oxygen saturation.
Incorrect options:
B) Palpate the skin for warmth and moisture - This technique may help to assess for other skin conditions, such as dehydration or infection, but it does not indicate cyanosis.
C) Compare the skin color with a standardized color chart - This technique may help to assess for other skin conditions, such as jaundice or anemia, but it does not indicate cyanosis.
D) Observe the skin for pallor or ashiness - This technique may help to assess for other skin conditions, such as shock or hypovolemia, but it does not indicate cyanosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
"I think that I can drive myself home after the procedure."
Rationale: The client should be informed that they cannot drive themselves home after the procedure, as they will be under the influence of sedation and may experience drowsiness, impaired judgment, and delayed reaction time. The client should arrange for a responsible adult to accompany them home and stay with them until the effects of sedation wear off.
Incorrect options:
A) "I understand that I will be sedated during the procedure." - This is a correct statement, as sedation is usually administered during a colonoscopy to reduce discomfort and anxiety.
B) "I know that I have to drink a lot of clear liquids before the procedure." - This is a correct statement, as drinking clear liquids before the procedure helps to cleanse the bowel and improve visualization.
C) "I expect that I will have some abdominal cramps and gas after the procedure." - This is a correct statement, as abdominal cramps and gas are common after a colonoscopy due to air insufflation during the procedure. The client should be advised to ambulate and pass gas as tolerated to relieve these symptoms.
Correct Answer is C
Explanation
Rales
Rationale: Rales are fine, high-pitched crackling sounds heard in the lungs due to fluid accumulation or inflammation. They are commonly heard in clients who have heart failure, pneumonia, or pulmonary edema.
Incorrect options:
A) Wheezes - Wheezes are high-pitched musical sounds heard in the lungs due to narrowed airways. They are commonly heard in clients who have asthma, chronic obstructive pulmonary disease (COPD), or bronchitis.
B) Rhonchi - Rhonchi are low-pitched snoring sounds heard in the lungs due to secretions or mucus in the large airways. They are commonly heard in clients who have bronchitis, cystic fibrosis, or pneumonia.
D) Stridor - Stridor is a high-pitched crowing sound heard in the upper airway due to obstruction or inflammation. It is commonly heard in clients who have croup, epiglottitis, or foreign body aspiration.
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