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.
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.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
The healthcare provider has prescribed 4,800 mg of magnesium hydroxide. The bottle indicates that each 5 mL contains 400 mg of magnesium hydroxide. We also know that 1 ounce (oz) is equivalent to 30 mL.
Step 1: The amount of magnesium hydroxide the patient needs is 4,800 mg.
Step 2: The concentration of the magnesium hydroxide solution is 400 mg per 5 mL. Step 3: Substitute the values into the formula: 4,800 mg ÷ (400 mg/5 mL).
Step 4: Calculate the volume in mL: 4,800 ÷ (400/5) = 60 mL.
Now, we need to convert this volume from mL to ounces.
Step 5: We know that 1 oz = 30 mL.
Step 6: Substitute the values into the formula: 60 mL ÷ 30 mL/oz.
Step 7: Calculate the volume in oz: 60 ÷ 30 = 2 oz.
Correct Answer is D
Explanation
The correct answer is choice D. Paper mask and gown.
Choice A rationale:
The stethoscope is not typically placed in a biohazard bag. It is cleaned and disinfected after each use, especially when used with a patient with an infectious disease like MRSA.
Choice B rationale:
Bed linens are usually placed in a designated linen bag, not a biohazard bag, even when the patient has an infectious disease. The linens are then laundered according to the healthcare facility’s infection control guidelines.
Choice C rationale:
A sputum specimen is typically placed in a designated specimen container, not a biohazard bag. The container is then sent to the lab for analysis.
Choice D rationale:
The paper mask and gown used while caring for a patient with MRSA should be placed in a designated biohazard bag before being removed from the room. This is because these items may have come into contact with the bacteria and could potentially spread the infection.
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