The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?
Heart rate.
Blood pressure.
Temperature.
Respiratory rate.
The Correct Answer is D
Choice A reason: While heart rate is important, it is not the most immediate concern when a client shows signs of cyanosis.
Choice B reason: Blood pressure is a critical vital sign but does not directly address the issue of oxygenation, which is suggested by cyanosis.
Choice C reason: Temperature is less relevant to the immediate assessment of cyanosis, which is often related to oxygenation issues.
Choice D reason: Respiratory rate should be assessed first as cyanosis is a sign of potential hypoxia, and the respiratory rate can provide immediate information about the client's breathing and oxygenation status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The appearance of a small, round raised area, known as a wheal, is a normal reaction to an intradermal injection and should be documented.
Choice B reason: This is not an allergic response but a normal reaction to an intradermal injection, so there is no need to notify the healthcare provider.
Choice C reason: There is no need to elevate the area or apply pressure as the raised area is a normal reaction to the medication being correctly placed in the dermis.
Choice D reason: Applying a cold pack is not necessary for a normal reaction to an intradermal injection.
Correct Answer is D
Explanation
The correct answer is choiced. Proceed with teaching the client how to walk with the crutches.
Choice A rationale:
Confer with the physical therapist for correct crutch size. This is unnecessary because the crutches are already correctly fitted.A space of three finger widths between the top of the crutch and the client’s axilla is appropriate to prevent pressure on the axilla and potential nerve damage.
Choice B rationale:
Ask the client to sit down while the crutch length is adjusted. This action is not needed since the crutches are already properly adjusted.Adjusting the crutch length further could lead to improper fitting, which might cause discomfort or injury.
Choice C rationale:
Assess the client for signs of diminished circulation in the hands. While assessing circulation is important, it is not directly related to the fitting of the crutches.Proper crutch fitting focuses on ensuring there is no pressure on the axilla and that the client can use the crutches comfortably.
Choice D rationale:
Proceed with teaching the client how to walk with the crutches. This is the correct action because the crutches are already properly fitted.The nurse should now focus on educating the client on the correct use of the crutches to ensure safe and effective mobility.
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