A nurse is performing a skin assessment on a client who has dark skin.
Which of the following techniques should the nurse use to detect cyanosis in this client?
Inspect the nail beds and lips for a bluish hue.
Palpate the skin for warmth and moisture.
Compare the skin color with a standardized color chart.
Observe the skin for pallor or ashiness.
The Correct Answer is A
Inspect the nail beds and lips for a bluish hue.
Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. In clients who have dark skin, cyanosis may be difficult to detect by visual inspection of the skin alone. The nurse should inspect the nail beds and lips for a bluish hue, as these areas are more sensitive to changes in oxygen saturation.
Incorrect options:
B) Palpate the skin for warmth and moisture - This technique may help to assess for other skin conditions, such as dehydration or infection, but it does not indicate cyanosis.
C) Compare the skin color with a standardized color chart - This technique may help to assess for other skin conditions, such as jaundice or anemia, but it does not indicate cyanosis.
D) Observe the skin for pallor or ashiness - This technique may help to assess for other skin conditions, such as shock or hypovolemia, but it does not indicate cyanosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Respiratory depression
Rationale: Respiratory depression is a life-threatening complication of substance abuse, especially opioid overdose, that requires immediate intervention. The nurse should report this finding to the provider and prepare to administer naloxone, an opioid antagonist, as prescribed.
Incorrect options:
A) Dilated pupils - This is a common finding in clients who abuse stimulants, such as cocaine or methamphetamine, but it is not an emergency.
B) Slurred speech - This is a common finding in clients who abuse depressants, such as alcohol or benzodiazepines, but it is not an emergency.
C) Agitation and restlessness - This is a common finding in clients who abuse stimulants, such as cocaine or methamphetamine, but it is not an emergency.
Correct Answer is A
Explanation
Inspect the nail beds and lips for a bluish hue.
Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. In clients who have dark skin, cyanosis may be difficult to detect by visual inspection of the skin alone. The nurse should inspect the nail beds and lips for a bluish hue, as these areas are more sensitive to changes in oxygen saturation.
Incorrect options:
B) Palpate the skin for warmth and moisture - This technique may help to assess for other skin conditions, such as dehydration or infection, but it does not indicate cyanosis.
C) Compare the skin color with a standardized color chart - This technique may help to assess for other skin conditions, such as jaundice or anemia, but it does not indicate cyanosis.
D) Observe the skin for pallor or ashiness - This technique may help to assess for other skin conditions, such as shock or hypovolemia, but it does not indicate cyanosis.
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