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 B

Explanation

Choice A rationale: Promotion of oxygenation by enhancing air circulation around the wound is not the primary treatment for a "yellow" wound.

Choice B rationale: Removal of nonviable tissue followed by a moist wound dressing is the expected treatment for a wound with yellow color, indicating the presence of slough (nonviable tissue).

Choice C rationale: Use of barrier cream and a foam dressing may be indicated for other types of wounds but may not address the specific issue of nonviable tissue in a "yellow" wound.

Choice D rationale: No treatment is necessary is not appropriate for a wound with evidence of nonviable tissue.

A. suctioning once every eight hours is a part of routine pulmonary nursing care. B. the physician has prescribed suctioning every hour. C. the client has thick sputum, and routinely coughs and swallows his sputum. D. the client has gurgling respirations, and is unable to cough.

Correct Answer is D

Explanation

Choice A rationale: Suctioning is not typically performed as part of routine pulmonary nursing care every eight hours. It is indicated based on the client's clinical need.

Choice B rationale: Suctioning frequency should be determined by the client's condition and physician's orders, not a fixed hourly schedule.

Choice C rationale: Routine coughing and swallowing of sputum do not necessarily warrant suctioning. Suctioning is indicated when the client is unable to manage secretions effectively.

Choice D rationale: Suctioning is appropriate when the client has gurgling respirations and is unable to cough effectively, indicating the need to clear the airway.

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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

On admission to the hospital, the nurse notes that the client has a sacral wound that is "yellow" in color. What wound treatment would the nurse expect the health care provider to order?

Correct Answer is B

Explanation

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

Correct Answer is D

Explanation

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:

The nurse is administering medications to a group of clients. Which client(s) warrant(s) the nurse's special attention when considering pharmacokinetics? The client(s) who has (have) a medical diagnosis of: (SELECT ALL THAT APPLY)

The nurse knows that which form of medication delivery results in the most predictable onset and most bioavailability to the client?

The nurse finds a client on bed rest experiencing clear signs of dyspnea. The nurse should assist the client to a:

A client has had an uncomplicated repair of an inguinal hernia. On the second post- operative day, the client has mildly elevated temperature and general malaise. The nurse recognizes that this is a generalized body response which is common to which phase of healing?

Chest physiotherapy (CPT) is ordered for a client with pneumonia. The nurse knows that the primary purpose of CPT for this client is to:

In order to minimize discomfort when giving an injection to a client, the nurse should:

A group that has transformed itself from a collection of individuals into a productive, problem-solving highly functioning team would be functioning in which stage of group development?