The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?

Heart rate.

Blood pressure.

Temperature.

Respiratory rate.

Answer and Explanation

The Correct Answer is D

Choice A reason: While heart rate is important, it is not the most immediate concern when a client shows signs of cyanosis.

Choice B reason: Blood pressure is a critical vital sign but does not directly address the issue of oxygenation, which is suggested by cyanosis.

Choice C reason: Temperature is less relevant to the immediate assessment of cyanosis, which is often related to oxygenation issues.

Choice D reason: Respiratory rate should be assessed first as cyanosis is a sign of potential hypoxia, and the respiratory rate can provide immediate information about the client's breathing and oxygenation status.

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Correct Answer is D

Explanation

Choice A reason: Printing the EMR from a backup server does not resolve the immediate issue of the system lockup and may not be possible if the system is down.

Choice B reason: Identifying information as a late entry is a step to take after the system issue has been resolved and does not address the current problem.

Choice C reason: Waiting for the system to be rebooted is passive and does not actively contribute to resolving the system lockup.

Choice D reason: Notifying the information services department is the first and most proactive step to take, as they are responsible for resolving technical issues with the EMR system.

A. Record the client's pulse rate and rhythm. B. Assist the client to stand at the bedside. C. Apply the blood pressure cuff securely. D. Position the client supine for a few minutes.

Correct Answer is D

Explanation

Choice A reason: Recording the client's pulse rate and rhythm is part of the assessment, but it is not the first action to take when assessing for orthostatic hypotension.
Choice B reason: Assisting the client to stand is part of the assessment process, but it should be done after the initial blood pressure and pulse have been measured while the client is supine.
Choice C reason: Applying the blood pressure cuff securely is necessary for an accurate reading, but it is not the first step in the process of assessing for orthostatic hypotension.
Choice D reason: The first action is to position the client supine for a few minutes before taking the initial blood pressure and pulse measurements, as this provides a baseline for comparison when the client stands.

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The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?

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Naxlex Comprehensive Predictor Exams

The nurse is entering prescriptions for laboratory work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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