A nurse performs an integumentary assessment of a client who has recently fallen and broken his leg. The nurse notes the skin coloring on the broken leg is bluish gray. What is the term for this change in skin color?

A. Assess the pedal pulses with a Doppler device:

Assessing the pedal pulses with a Doppler device may be useful in certain situations, but when the radial pulse is irregular, it's more important to assess the central (apical) pulse to get a more accurate representation of the heart's rhythm.

B. Assess the apical pulse with a Doppler device:

While using a Doppler device on the apical pulse is an option, it's generally not the first choice when assessing irregular pulses. The apical pulse can often be palpated manually, and it's more practical to assess it directly for irregularities.

C. Assess the apical pulse for a full minute:

This is the recommended action when the radial pulse is irregular. By assessing the apical pulse for a full minute, the nurse can accurately determine the heart rate and identify any irregularities in rhythm, providing a comprehensive assessment of the cardiac status.

D. Assess the pedal pulses for a full minute:

While assessing the pedal pulses is important in certain situations, it may not be the priority when dealing with an irregular radial pulse. Assessing the apical pulse for a full minute gives a more direct and accurate reflection of the heart's rhythm.

A. Place the client on bed rest in supine position:

While bed rest might be appropriate for certain respiratory conditions, it is not a specific intervention for crackles. In fact, changing the client's position, such as having them sit up, may enhance lung function and help with breathing.

B. Repeat auscultation after asking the client to breathe deeply and cough:

This is the correct action. Repeating auscultation after having the client take deep breaths and cough can provide additional information about the nature of the crackles and may help clear the airways temporarily.

C. Prepare to administer antibiotics:

Administering antibiotics would be considered if the crackles are indicative of a respiratory infection. However, determining the need for antibiotics would require a more comprehensive assessment, including diagnostic tests.

D. Instruct the client to limit fluid intake to less than 2,000 mL/day:

Limiting fluid intake is not a direct intervention for crackles. This action is typically considered in conditions like heart failure where there is a risk of fluid overload. It is not the primary intervention for addressing crackles in the lungs.