how should the nurse assess for cyanosis in a client with dark skin who is in respiratory distress
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Nursing Elites

HESI LPN

Adult Health 2 Exam 1

1. How should the nurse assess for cyanosis in a client with dark skin who is in respiratory distress?

Correct answer: C

Rationale: Observing the lips and mucous membranes provides a reliable indicator of cyanosis in clients with dark skin tones. Choice A is incorrect because cyanosis can be assessed in clients with dark skin by observing other body areas. Choice B is incorrect as blanching the soles of the feet is not a relevant method for assessing cyanosis. Choice D is incorrect as cyanosis is not typically seen in the sclera in clients with dark skin.

2. The wife is observed shaving her husband's beard with a safety razor. What should the nurse do?

Correct answer: C

Rationale: In this situation, the nurse should encourage the wife to continue shaving her husband. The rationale behind this is that the wife is already performing the task, so abrupt interference may lead to potential harm or emotional distress. It is crucial for the nurse to carefully observe the situation and assess for any safety concerns. While teaching proper techniques (Choice B) is important, it can be addressed later in a non-critical manner to prevent skin irritation and injury. Advising to shave against the hair growth (Choice A) may cause skin irritation and cuts. Although demonstrating the correct procedure (Choice D) may be helpful, it is essential to consider the current dynamics and respect the wife's autonomy in caring for her husband.

3. A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulant therapy. Which instruction should the nurse provide to the client?

Correct answer: B

Rationale: Reporting signs of bleeding is essential while on anticoagulant therapy to prevent complications.

4. A client with a diagnosis of chronic heart failure is prescribed digoxin. What is the most important assessment before administering this medication?

Correct answer: B

Rationale: The correct answer is to assess the heart rate before administering digoxin. Digoxin can lead to bradycardia, making it crucial to evaluate the heart rate to prevent potential complications. Checking blood pressure (Choice A) is important but not as critical as assessing the heart rate in this context. Monitoring respiratory rate (Choice C) and measuring oxygen saturation (Choice D) are not the most crucial assessments before administering digoxin, as the primary concern with this medication is its impact on heart rate.

5. The healthcare provider is assessing a client who has just undergone a thyroidectomy. Which assessment finding is most concerning?

Correct answer: C

Rationale: Tingling around the mouth is the most concerning finding as it may indicate hypocalcemia, a potential complication after thyroidectomy. Hoarseness of the voice is common due to surgical manipulation, slight swelling at the incision site is expected postoperatively, and mild fever can be a normal inflammatory response. Hypocalcemia after thyroidectomy can lead to serious complications and should be addressed promptly to prevent further issues.

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