The nurse is assessing the patient's lips and notes a bluish tinge. This finding would indicate that the patient may be experiencing which problem?
Inflammation of the lips
Hypoxia
Beginning of a liver blister
Lack of dental care
The Correct Answer is B
Hypoxia is a medical condition characterized by a lack of oxygen in the body's tissues, which can occur due to a variety of reasons, such as respiratory failure, cardiac arrest, or other serious medical conditions. Cyanosis occurs when the oxygen saturation level in the blood falls below 85%, which causes a bluish color to appear on the skin, especially on the lips and fingertips. Therefore, if a nurse observes cyanosis in a patient's lips, it is a significant sign of hypoxia, and the patient requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A.This option is appropriate for children under the age of 3. Pulling the pinna down and back straightens the ear canal in young children, but it does not align the canal correctly in adults.
B.For an adult, the correct method to straighten the ear canal during examination is to pull the pinna (outer part of the ear) up and back. This maneuver aligns the ear canal for better visualization of the tympanic membrane (eardrum) and inner structures.
C.Pulling the pinna down and forward is incorrect for both adults and children. This action would not provide a clear view of the ear canal and could make examination difficult.
D.Pulling the pinna straight back does not fully straighten the ear canal in adults and may make the examination less effective. The correct technique is up and back for adults to fully straighten the canal and enhance visualization.
Correct Answer is B
Explanation
The SBAR (Situation, Background, Assessment, Recommendation) system is a standardized way of communicating critical information between healthcare professionals, particularly during patient handoffs or when escalating a concern.
The recommendation component is where the healthcare professional providing the report suggests a course of action or plan for the patient based on the situation, background, and assessment. For example, a recommendation might be, "I recommend increasing Mr. Smith's pain medication to manage his discomfort," or "I recommend a consult with the nutritionist to address Mrs. Brown's malnutrition."
Of the options provided, (a) provides the situation, (c) provides the assessment, and (d) provides a specific finding from the assessment. Option (b) is a specific recommendation or plan.
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