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 A

Explanation

Choice A reason: If the oxygen reservoir bag of a partial rebreather mask does not deflate completely during inspiration, it may indicate that the flow rate is too low. Increasing the liter flow ensures adequate delivery of oxygen.

Choice B reason: Encouraging the client to take deep breaths is beneficial for overall respiratory function but will not address the issue of the reservoir bag not deflating properly.

Choice C reason: Removing the mask to deflate the bag is not a standard practice and could interrupt the delivery of oxygen to the client.

Choice D reason: Documentation of the assessment data is important, but the nurse must first address the issue with the oxygen delivery system to ensure the client is receiving the proper amount of oxygen.

A. "I'm sorry, but your sibling's medical information is none of your business." B. "I can give you those results as soon as I get them back from the lab." C. "I can only give medical information to the client with an approved interpreter." D. "The healthcare provider will share this information with you."

Correct Answer is C

Explanation

Choice A reason: This response is inappropriate and dismissive of the sibling's concern and the client's need for communication assistance.

Choice B reason: Providing medical information to someone who is not an approved interpreter could breach confidentiality and privacy regulations.

Choice C reason: It is important to use an approved interpreter to ensure accurate and confidential communication of medical information.

Choice D reason: While the healthcare provider will share information, it is essential to use an approved interpreter to facilitate understanding and maintain confidentiality.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during respiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?

Correct Answer is A

Explanation

A client, who speaks very little English, is being seen in the emergency department following an automobile accident. The client's sibling offers to act as an interpreter and asks about the laboratory results. Which response is best for the nurse to provide?

Correct Answer is C

Explanation

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