A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Dorsal surface of the foot

Dorsal surface of the hand

Pinnae of the ears

Conjunctivae

Answer and Explanation

The Correct Answer is D

A) The dorsal surface of the foot is not the most reliable site to assess for cyanosis in individuals with dark skin because the skin pigmentation can mask the bluish tint that indicates reduced oxygenation.
B) Similarly, the dorsal surface of the hand may not clearly show cyanosis due to the thickness and pigmentation of the skin, which can obscure the color change.
C) The pinnae of the ears may also not be the best indicator of cyanosis in dark-skinned individuals because peripheral areas like the ears can be affected by environmental temperatures, leading to misleading color changes.
D) The conjunctivae, however, are a mucous membrane where the skin pigmentation does not affect visibility. Therefore, it is an appropriate site for assessing cyanosis as it allows for the observation of subtle changes in color that indicate hypoxia. This is why the conjunctivae are the correct site to examine for cyanosis in a client with dark skin.

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Correct Answer is B

Explanation

A. The reported tympanic temperature of 37.1°C (98.8°F) is within normal range.
B. The blood pressure (BP) reading of 98/58 mm Hg indicates a relatively low diastolic pressure. Diastolic pressure is an important indicator of perfusion to vital organs, especially the coronary arteries and the brain. It's crucial to ensure that this reading is accurate.
C. The reported pulse rate of 92/min falls within the normal range for an adult at rest.
D. The reported respiratory rate of 18/min is within the normal range for an adult at rest.

A. Rub hands and arms to dry. B. Adjust the water temperature to feel hot. C. Apply 4 to 5 mL of liquid soap to the hands. D. Hold the hands higher than the elbows.

Correct Answer is C

Explanation

A. Rubbing hands and arms to dry is not the correct action for hand hygiene. After applying soap, hands should be rinsed thoroughly with water and then dried using a clean towel or air dryer.
B. Adjusting the water temperature to feel hot is not recommended for hand hygiene.
Water that is too hot can be uncomfortable and may even cause skin irritation. The water should be comfortably warm.
C. Applying 4 to 5 mL of liquid soap to the hands is the correct action. This provides an adequate amount of soap to create a good lather for effective handwashing.
D. Holding the hands higher than the elbows is not a necessary step for hand hygiene.
The focus should be on thoroughly cleaning the hands, not on the position of the hands in relation to the elbows.

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A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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