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 {"dropdown-group-1":"B"}

Explanation

Choice A rationale: Stage I pressure ulcers involve intact skin with non-blanchable redness, and there is no mention of intact skin in the scenario.

Choice B rationale: Stage II pressure ulcers involve partial thickness skin loss, typically presenting as an abrasion, blister, or shallow crater, which aligns with the description provided.

Choice C rationale: Stage III pressure ulcers involve full-thickness skin loss with damage to or necrosis of subcutaneous tissue but do not match the described scenario.

Choice D rationale: Stage IV pressure ulcers involve full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, which does not align with the description of partial thickness skin loss in the scenario.

A. tell the nurse manager. B. notify the physician. C. check the client's blood pressure. D. file an incident report.

Correct Answer is C

Explanation

Choice A rationale: Telling the nurse manager is not the first action; the immediate focus should be on the client's well-being.

Choice B rationale: Notifying the physician is important, but the immediate concern is addressing the client's condition.

Choice C rationale: Checking the client's blood pressure is the first action to assess the client's response to the medication error.

Choice D rationale: Filing an incident report is important for documenting the error but is not the immediate action in this situation.

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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

When doing the client's skin assessment, the nurse notes a 3 cm area of partial thickness skin loss that looks like a blister on the client's sacral area. The nurse consults the wound care nurse, who stages the wound as a dropdown pressure ulcer.

Correct Answer is {"dropdown-group-1":"B"}

Explanation

The nurse misreads the medication Kardex and administers twice the amount of antihypertensive medication that was ordered for the client. When she realizes the mistake, her first action should be to:

Correct Answer is C

Explanation

Which nursing action is most helpful in thinning a client's thick respiratory secretions?

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)

A client must receive eyedrops bilaterally four times a day. The medication should be dropped onto which of the following areas?

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