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 C
Explanation
The correct answer is choice c. Place padding around the cannula tubing.
Choice A rationale:
Discontinuing the use of the nasal cannula is not appropriate because the client still needs supplemental oxygen to maintain adequate oxygen saturation levels.
Choice B rationale:
Applying lubricant to the cannula tubing might help reduce friction but does not address the pressure that is causing the red mark.
Choice C rationale:
Placing padding around the cannula tubing helps to alleviate the pressure on the skin, which can prevent further irritation and allow the red mark to heal.
Choice D rationale:
Decreasing the flow rate to 1 L/minute could compromise the client’s oxygenation status, as the current flow rate is necessary to maintain an oxygen saturation level of 94%.
Correct Answer is C
Explanation
The correct answer is choice C. “This must be a very difficult time for you.”
Choice A rationale:
Asking the mother why she thinks it is her fault can make her feel defensive and does not provide the emotional support she needs at this moment. It may also imply that there could be a reason for her to feel guilty, which is not helpful.
Choice B rationale:
While it is important to provide hope and information about the prognosis, this response does not address the mother’s immediate emotional distress and feelings of guilt. It focuses on the future rather than acknowledging her current emotional state.
Choice C rationale:
This response is empathetic and acknowledges the mother’s feelings. It provides emotional support and validates her experience, which is crucial in helping her cope with the situation.
Choice D rationale:
Telling the mother she did nothing wrong is important, but it does not fully address her emotional distress. It is a factual statement that may not provide the comfort and understanding she needs at this moment.
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