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 A

Explanation

A. This statement is incorrect. While HIPAA allows for certain disclosures to family members, it is important to follow specific guidelines and obtain appropriate consent or authorization from the client when sharing their health information. There are also circumstances where a client may request that information be withheld from certain family members.
B. This statement is correct. HIPAA is a federal law that establishes privacy standards for protected health information.
C. This statement is correct. A client's address is considered personally identifiable information under HIPAA.
D. The statement appears to be cut off. However, it is important to note that HIPAA does indeed establish regulations for protecting individually identifiable health information in various forms, including verbal, electronic, and written.

A. Dilute each medication with 10 mL of tap water. B. Pinch the tube prior to attaching the medication syringe. C. Reattach the suction directly after administering the medication. D. Mix the three medications together prior to administering.

Correct Answer is B

Explanation

A. Diluting each medication with tap water is not a recommended practice. It's important to administer medications in their prescribed form to ensure the client receives the correct dose.
B. Pinching the tube prior to attaching the medication syringe helps prevent the medication from being immediately pulled into the suction equipment. This allows the medication to stay in the stomach for absorption.
C. Reattaching the suction directly after administering the medication would
immediately start suctioning again, which could pull the medication out of the stomach before it has a chance to be absorbed.
D. Mixing the three medications together is not recommended, as some medications may interact with each other, potentially leading to undesirable effects. Each medication should be administered separately to ensure proper absorption and effectiveness.

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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

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