A nurse is performing a skin assessment on a client who has dark skin.
Which of the following locations on the client’s body should the nurse observe to assess for cyanosis?
Area of trauma.
Sacrum.
Shoulders.
Palms of the hands.
The Correct Answer is D
Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. It is more difficult to detect in people who have dark skin, so the nurse should look for cyanosis in areas where the skin is thinner and the blood supply is richer, such as the palms of the hands, the lips, the gums, and around the eyes.
These areas are less affected by melanin, the pigment that gives skin its color.
Choice A is wrong because an area of trauma may have bruising or inflammation that can mask cyanosis.
Choice B is wrong because the sacrum is not a good site to assess for cyanosis in any skin tone, as it is prone to pressure ulcers and poor circulation.
Choice C is wrong because the shoulders are not a mucous membrane and may have more melanin than other areas of the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiced. A client who is taking warfarin and has an INR of 1.8.
Choice A rationale:
An induration after a Mantoux test indicates a positive reaction, but it does not necessarily require immediate follow-up unless the induration is significant and the client has risk factors for tuberculosis.
Choice B rationale:
Sodium phosphate is commonly used as a bowel preparation for colonoscopy. This does not typically require follow-up unless the client experiences adverse effects such as dehydration or electrolyte imbalance.
Choice C rationale:
A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L). Therefore, this finding does not require follow-up.
Choice D rationale:
An INR of 1.8 for a client taking warfarin is below the therapeutic range for most indications (typically 2.0-3.0). This requires follow-up to adjust the warfarin dosage to achieve the desired anticoagulation effect.
Correct Answer is ["C"]
Explanation
C. “I will eat small, frequent meals.”.
This statement indicates an understanding of the discharge teaching because eating small, frequent meals can help reduce the workload of the pancreas and prevent pain and nausea.
A. “I will eat fish for dinner at least twice per week.” This statement does not indicate an understanding of the discharge teaching because fish is a high-fat food that can aggravate pancreatitis. The client should eat a low-fat diet with no more than 30 grams of fat per day.
B. “I will limit my morning coffee to no more than two cups.” This statement does not indicate an understanding of the discharge teaching because coffee is a caffeinated beverage that can stimulate the pancreas and worsen the inflammation. The client should avoid caffeine and alcohol.
D. “I should expect my bowel movements to be pale in color”. This statement does not indicate an understanding of the discharge teaching because pale stools can be a sign of bile duct obstruction or pancreatic insufficiency, which are complications of pancreatitis. The client should notify the provider if they notice any changes in their stool color or consistency.
E. “I will notify my provider if my urine is dark.” This statement does not indicate an understanding of the discharge teaching because dark urine can be a sign of dehydration or jaundice, which are also complications of pancreatitis. The client should drink plenty of fluids and monitor their skin and eyes for yellowing.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.