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?

A:Provide frequent rest periods for the client. This is correct because the client has anaemia (low haemoglobin and hematocrit), which can cause weakness and fatigue. Rest periods can help conserve energy and prevent complications.
B:Instruct the client to avoid blowing their nose forcefully. This is correct because the client has thrombocytopenia (low platelet count), which can increase the risk of bleeding. Blowing the nose forcefully can cause nasal bleeding or rupture of blood vessels.
C: Assess the client’s level of orientation. This is correct because the client has hepatic encephalopathy (brain dysfunction due to liver failure), which can cause confusion, mood changes, and disorientation. Assessing the client’s level of orientation can help monitor the severity of hepatic encephalopathy and guide appropriate interventions.
D:Place the client on a low-carbohydrate diet. This is incorrect because a low-carbohydrate diet can worsen hepatic encephalopathy by increasing ammonia production in the gut. The client should be on a high-protein, high-calorie diet to provide adequate nutrition and prevent muscle wasting.
E: Restrict the client’s sodium intake. This is correct because the client has ascites (fluid accumulation in the abdomen) due to portal hypertension (high blood pressure in the portal vein). Restricting sodium intake can help reduce fluid retention and prevent further complications.
F Advise the client to avoid the use of soap and alcohol-based lotions. This is correct because the client has pruritus (itching) due to high bilirubin levels in the blood. Soap and alcohol-based lotions can dry out the skin and worsen pruritus. The client should use mild cleansers and moisturizers to soothe the skin.
G: Place the client under contact isolation. This is incorrect because there is no indication that the client has an infectious disease that requires contact isolation. Contact isolation is used for clients who have diseases that can be transmitted by direct or indirect contact with the client or their environment, such as Clostridioides difficile infection or methicillin-resistant Staphylococcus aureus infection.

The correct answer is choice C. Blow into the meter as hard and quickly as possible.

This is because a peak flow meter measures how fast you can push air out of your lungs when you blow out as hard and as fast as you can.

This is called peak expiratory flow rate (PEFR) or peak expiratory flow (PEF). It shows how open the airways are in the lungs and can help detect early signs of worsening asthma.

Choice A is wrong because maintaining a semi-Fowler’s position during testing is not necessary. You can sit or stand up straight, but make sure you do it the same way each time.

Choice B is wrong because placing tongue on the mouthpiece of the meter can block the air flow and affect the accuracy of the measurement. You should close your lips tightly on the mouthpiece instead.

Choice D is wrong because recording the average of the readings is not recommended.

You should record the highest of the three readings on a sheet of paper, calendar or in your asthma diary. This is your daily peak flow.

Normal ranges for peak flow vary depending on age, height, gender and race. You can use a chart or calculator to find out your predicted normal peak flow based on these factors. However, it is more important to find out your personal best peak flow by performing peak flow testing twice a day for two weeks when your asthma is under good control. Your personal best peak flow will be used to create your asthma action plan with your healthcare provider.