The nursing assessment finding that represents the most serious indication of a client's deteriorating oxygenation status is:

pursed-lip breathing.

clubbing of the nails.

cyanosis.

poor skin turgor.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Pursed-lip breathing is a compensatory mechanism to improve oxygenation and is not as severe an indication as cyanosis.

Choice B rationale: Clubbing of the nails is a chronic sign of oxygenation issues but may not be an acute and immediate indication of deterioration.

Choice C rationale: Cyanosis, the bluish discoloration of the skin and mucous membranes, is a serious indication of inadequate oxygenation.

Choice D rationale: Poor skin turgor is not a direct indicator of oxygenation status.

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Correct Answer is C

Explanation

Choice A rationale: The normal stimulus to breathe is an increased carbon dioxide level, which stimulates the respiratory center in the brain.

Choice B rationale: Increased oxygen levels do not serve as the primary stimulus for breathing. The respiratory center is primarily responsive to carbon dioxide levels.

Choice C rationale: Increased carbon dioxide level is the correct stimulus for normal breathing.

Choice D rationale: Decreased oxygen level is not the primary stimulus for normal breathing.

A. protect the wound from additional pressure. B. provide moisture to the wound. C. enhance healing by primary intention. D. absorb the wound drainage.

Correct Answer is B

Explanation

Choice A rationale: Protecting the wound from additional pressure is more commonly achieved with pressure-relieving devices.

Choice B rationale: Providing moisture to the wound is the primary purpose of a hydrogel dressing, promoting a moist wound environment for healing.

Choice C rationale: Enhancing healing by primary intention is more related to surgical wound closure rather than the use of a hydrogel dressing.

Choice D rationale: Absorbing wound drainage is not the primary purpose of a hydrogel dressing, as its focus is on providing moisture.

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The nursing assessment finding that represents the most serious indication of a client's deteriorating oxygenation status is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In providing care for clients, the nurse knows that the normal stimulus to breathe is a/an:

Correct Answer is C

Explanation

The client has an open wound on the sacrum with an order for the following: "Apply hydrogel dressing on the wound. Change dressing every day." The nurse recognizes that the primary purpose of this dressing is to:

Correct Answer is B

Explanation

An advantage of delegation in client care is that:

The nurse is to administer a volume of 2 mL intramuscularly (IM) to a 150-pound client. Assuming that there are no skin problems, which is the preferred site for the injection?

Which one of the following blood levels would provide the nurse with the most information about the ability of the client's blood to transport oxygen? The:

A client has a serum potassium level of 6.3 mEq/L. The nurse recognizes that the highest priority intervention(s) for this client are to: (SELECT ALL THAT APPLY)

The nurse recognizes that the most appropriate reason to suction a client is that:

A nurse receives an order for blood, urine, stool and nasal cultures on a client with a high fever. Which prefix describes this order?

The nurse understands that the rationale(s) for clients receiving intravenous (IV) therapy is/are to: (SELECT ALL THAT APPLY)

The nurse notes that a diuretic is listed on the client's medication administration record (MAR). It is most important for the nurse to report to the physician a serum: