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. Reporting the incident to the charge nurse is an important step, but it should come after the immediate action of washing the affected area.
B. Washing the area of the puncture thoroughly with soap and water is the initial step in managing a needlestick injury to minimize the risk of infection.
C. Going to employee health services is important for further assessment and follow-up, but it should be done after washing the area of the puncture.
D. Completing an incident report is an essential part of documenting the needlestick injury, but it is a secondary step that should be taken after the initial action of washing the area.

A. Goggles B. Gown C. Mask D. Gloves

Correct Answer is C

Explanation

A. Goggles are not typically necessary for droplet precautions unless there is a risk of splashing or spraying of respiratory secretions.
B. A gown is not specifically required for droplet precautions. However, if there is a risk of contamination from respiratory secretions, a gown may be used in addition to other precautions.
C. When setting up a meal tray for a client requiring droplet precautions, the nurse should wear a mask to protect against potential exposure to respiratory droplets.
D. Gloves are not typically required for setting up a meal tray under droplet precautions, as there is no direct contact with potentially contaminated surfaces.

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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?

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