A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?
Soles of the feet
Ear lobes
Oral mucosa
Conjunctivae
The Correct Answer is C
This is because central cyanosis reflects a decrease in arterial oxygen saturation and is best seen in areas where blood vessels are close to the surface, such as the oral mucosa, tongue, and lips. Peripheral cyanosis, which may be caused by vasoconstriction or poor circulation, can be seen in the soles of the feet, ear lobes, and nail beds, but it does not necessarily indicate hypoxemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should also advise the client to drink fluids between meals, eat small frequent meals, and increase protein intake to maintain muscle mass and immune function.
Correct Answer is D
Explanation
CD4-T-cell count 180 cells/mm3 is the nurse's priority. Rationale: This is because a low CD4-T-cell count indicates a high risk of opportunistic infections and impaired immune function. The nurse should implement infection prevention measures and monitor the client for signs of infection. The other values are not as critical as the CD4-T-cell count.
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