The nurse is performing an assessment of a client admitted to the emergency department with respiratory distress. The nurse should carefully inspect which part of the body to identify central cyanosis?

Oral mucosa

Palms

Sclera

Nail beds

Answer and Explanation

The Correct Answer is A

A. Oral mucosa is correct. Central cyanosis occurs when oxygen saturation is significantly reduced and is best assessed in areas with rich vascular supply, such as the oral mucosa, lips, and tongue.
B. Palms are incorrect because peripheral cyanosis (often due to cold exposure or poor circulation) can cause blue-tinged extremities, but this does not indicate central cyanosis.
C. Sclera is incorrect because cyanosis does not affect the sclera; however, jaundice does.
D. Nail beds are incorrect because, like the palms, they are more indicative of peripheral cyanosis, which can result from localized poor perfusion rather than central oxygenation problems.

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Correct Answer is C

Explanation

A. Wearing gloves before touching the client is not necessary unless the nurse anticipates contact with bodily fluids, non-intact skin, or mucous membranes.
B. Using a separate, disposable blood pressure cuff is an example of transmission-based precautions, not standard precautions, unless the client has an infection requiring contact precautions.
C. Wearing gloves to palpate the tongue and buccal membranes is correct because standard precautions require gloves when there is potential contact with mucous membranes, which can expose the nurse to infectious agents.
D. Wearing a gown, gloves, and mask is unnecessary unless the client has an infection that requires additional precautions beyond standard precautions.

A. "Have you experienced hypoglycemia recently?" B. "Are you currently taking any diuretic medications?" C. "What types of foods do you purchase?" D. "What kind of over-the-counter dietary supplements do you take?"

Correct Answer is B

Explanation

A. Hypoglycemia is not a primary cause of dehydration, though it can contribute to other symptoms.
B. Asking about diuretic medications is correct because diuretics increase urine output, which can lead to fluid loss and dehydration, particularly in older adults who may not adequately compensate with fluid intake.
C. The types of food purchased can influence hydration status but are not a primary factor in acute dehydration.
D. Over-the-counter supplements may have effects on hydration, but they are not the most immediate concern when assessing risk factors for dehydration.

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The nurse is performing an assessment of a client admitted to the emergency department with respiratory distress. The nurse should carefully inspect which part of the body to identify central cyanosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which action below?

Correct Answer is C

Explanation

An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize?

Correct Answer is B

Explanation

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