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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Elevating the bed for the comfort of the nurse does not address the safety and comfort of the client during the transfer.
B. While it's important to have assistance if needed, using several people to lift the client may not always be necessary or appropriate.
C. This positioningis not optimal, as it makes it harder for the client to pivot and sit on the wheelchair.
D. Ensuring the wheels of both the bed and the wheelchair are locked helps maintain stability and safety during the transfer process, reducing the risk of accidental movement and potential falls.
Correct Answer is C
Explanation
A. Inguinal canal is not the correct location for assessing the posterior tibial pulse. This area is associated with the femoral pulse.
B. The knee is not the correct location for assessing the posterior tibial pulse. This area is not directly related to the posterior tibial pulse.
C. The lower third of the tibia, anterior aspect is the correct location for palpating the posterior tibial pulse. This pulse can be found on the inside of the ankle, slightly below and behind the medial malleolus.
D. Dorsal aspect of the foot is where the dorsalis pedis pulse is located, not the posterior tibial pulse.
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