When gathering data about a client with dark skin tones, which site should the practical nurse (PN) observe?
Hands and feet.
Forehead and face.
Finger and toe nails.
Sclera and mucous membranes.
The Correct Answer is D
This is the best site for the PN to observe because it allows for the detection of changes in color, such as pallor, cyanosis, or jaundice, that may not be visible on the skin surface. The sclera and mucous membranes are less pigmented than the skin and reflect the underlying blood flow and oxygenation.
A. Hands and feet are not the best site for the PN to observe because they may be affected by peripheral circulation, temperature, or edema, which can alter the color of the skin.
B. Forehead and face are not the best site for the PN to observe because they may have increased pigmentation or variations in tone that can mask changes in color.
C. Finger and toenails are not the best site for the PN to observe because they may be affected by nail polish, fungal infection, or trauma, which can alter the color of the nails.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Enrollment in a remedial education class is unnecessary because the UAP is currently demonstrating the correct, evidence-based technique for providing oral care to an unconscious client to prevent aspiration.
Choice B rationale: While positive reinforcement is beneficial, the primary focus should be on the clinical safety of the procedure. Encouraging family participation is secondary to ensuring the UAP maintains proper safety protocols.
Choice C rationale: The side-lying position, combined with a towel and basin under the chin, allows secretions to drain out of the mouth by gravity. This is the safest position to prevent aspiration.
Choice D rationale: Placing an unconscious client in Fowler's position increases the risk of the tongue falling back and secretions being aspirated into the lungs. The flat, side-lying position is much safer.
Correct Answer is B
No explanation
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