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 B

Explanation

Choice A reason: The Trendelenburg position is not indicated for increasing oxygen saturation and could be harmful, especially for clients with respiratory distress.

Choice B reason: Ensuring that the prongs of the nasal cannula are securely placed in the nostrils is important for effective oxygen delivery, especially if the oxygen saturation remains below the prescribed range.

Choice C reason: Placing the pulse oximeter on the client's earlobe is an alternative site for obtaining a saturation reading, but it does not address the issue of potentially inadequate oxygen delivery.

Choice D reason: While documentation is important, the nurse must first address the low oxygen saturation levels before documenting the readings.

A. Complete the intermittent suction of the nasopharynx. B. Apply an oxygen mask over the client's nose and mouth. C. Reposition the pulse oximeter clip to obtain a new reading. D. Stop suctioning until the pulse oximeter reading is above 95%.

Correct Answer is A

Explanation

Choice A reason: If the oxygen saturation remains stable during the procedure, it indicates that the suctioning is not adversely affecting the client's oxygenation, and the nurse can safely continue.

Choice B reason: Applying an oxygen mask is not necessary if the oxygen saturation is stable and within a safe range.

Choice C reason: Repositioning the pulse oximeter clip is only necessary if there is a concern about the accuracy of the reading, not when the reading is stable.

Choice D reason: There is no need to stop suctioning if the oxygen saturation is stable at 94%, as this is within the acceptable range for most clients.

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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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Correct Answer is B

Explanation

While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

Correct Answer is A

Explanation

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