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 D
Explanation
Choice A reason: Dizziness is not typically associated with perineal care and is not relevant to the instructions.
Choice B reason: Advising to keep the pubic area shaved is not a standard part of perineal care instructions and is a personal choice.
Choice C reason: The statement about not retracting the foreskin is incorrect; the foreskin should be retracted gently for cleaning and then returned to its normal position to prevent infection.
Choice D reason: It is important to inform the caregiver that an erection may occur as a natural reflex during perineal care, and it does not indicate any sexual intent. This helps prepare the caregiver to handle the situation professionally.
Correct Answer is C
Explanation
Choice A reason: Completing an admission assessment is typically the responsibility of a registered nurse (RN) due to the comprehensive nature of the assessment.
Choice B reason: Accessing a central venous line is usually within the scope of practice of an RN, not a PN, due to the complexity and potential complications associated with central lines.
Choice C reason: Reinforcing discharge teaching is an appropriate task for a PN, as it involves reviewing and ensuring the client understands the instructions already provided by the RN or healthcare provider.
Choice D reason: Initiating blood product infusions is generally the responsibility of an RN because of the critical nature of the task and the potential for adverse reactions.
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