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 D
Explanation
Choice A reason: Dizziness is not typically associated with perineal care and is not relevant to the instructions.
Choice B reason: Advising to keep the pubic area shaved is not a standard part of perineal care instructions and is a personal choice.
Choice C reason: The statement about not retracting the foreskin is incorrect; the foreskin should be retracted gently for cleaning and then returned to its normal position to prevent infection.
Choice D reason: It is important to inform the caregiver that an erection may occur as a natural reflex during perineal care, and it does not indicate any sexual intent. This helps prepare the caregiver to handle the situation professionally.
Correct Answer is A
Explanation
Choice A reason: Providing a back massage and gentle efleurage can help alleviate pain through relaxation
techniques and is a non-pharmacological method to manage pain.
Choice B reason: Guided imagery and slow rhythmic breathing are helpful relaxation techniques, but they may not be as immediately effective for incisional pain as direct physical interventions.
Choice C reason: The use of a hot water circulation device should be done with caution postoperatively, as it may not be appropriate depending on the surgical site and the client's condition.
Choice D reason: Distraction techniques like watching television or listening to music can be helpful, but they may not address the physical component of the client's incisional pain.
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