A nurse is collecting data from a client who is African-American. Which of the following areas should the nurse check to determine the presence of pallor?
Conjunctiva
Pinna of the ear
Abdomen
Antecubital space
The Correct Answer is A
The correct answer is choice A. The nurse should check the conjunctiva to determine the presence of pallor in a client who is African-American. Choices B, C, and D are incorrect because pallor is not expected in these areas. Choice B is not correct because pallor is not expected in the pinna of the ear. Choice C is not correct because pallor is not expected in the abdomen. Choice D is not correct because pallor is not expected in the antecubital space.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Advise the client about increased dry mouth. Transdermal clonidine can cause xerostomia, or dry mouth, due to a decrease in salivary secretion. The nurse should advise the client to maintain good oral hygiene and to increase fluid intake to prevent oral and dental problems.
An explanation for incorrect choices:
A. Weight loss is not a common adverse effect or risk associated with transdermal clonidine.
C. Diarrhea can occur with transdermal clonidine, but it is not a common adverse effect or risk.
D. Hypopigmentation is rare with transdermal clonidine; it is more common with corticosteroids.
Correct Answer is D
Explanation
The correct answer is choice D. Provide regular oral care for the client with a moist swab. When a client with a terminal illness and in the active phase of dying refuses further hydration and nourishment, the nurse should provide comfort measures such as regular oral care to prevent discomfort. The nurse should not force the client to eat or drink or request a prescription for IV fluids. The healthcare surrogate cannot be asked for permission to withhold nourishment as the client has the right to refuse nourishment.
Option A - The client has the right to refuse nourishment, and healthcare surrogate permission is not required.
Option B - Requesting a prescription for IV fluids is not an appropriate intervention as the client has the right to refuse nourishment.
Option C - Explaining the importance of oral hydration to the client is not an appropriate intervention as the client has the right to refuse nourishment.
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