The nurse is triaging a client and notes pallor and cyanosis of the oral cavity and lips. Which action by the nurse is the priority based on the assessment data?
1. Administer IV fluids.
2. Provide oral hygiene.
3. Administer oxygen.
4. Provide a warm drink.
Correct Answer: 3
Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate hypoxia. The nurse should apply oxygen for the client. There is no indication the client has an electrolyte or fluid imbalance at this time, making the administration of IV fluids inappropriate at this time. Providing oral hygiene is not an appropriate intervention because it will not increase the client's oxygenation levels. Providing a warm drink will not correct the client's oxygenation problem.
You might also like to view...
A client's caregiver opens the door to the client's home, and the home health nurse enters to find the elderly client sitting up in a chair. The client states, "I have not been myself lately and I am hearing things that frighten me."
The nurse assesses the client and discusses with her that the new medication that the physician put her on may be causing these symptoms. The caregiver states, "She was like this before she was put on the medicine." As she charts, the nurse comments on the flowers that the client received and states that they are beautiful. What nontherapeutic communication technique occurred? A) Changing the subject B) Exhibiting judgmental behaviors C) Stereotyping the individual D) Failing to listen
Convert 0.7% to a decimal: ___________
Fill in the blank(s) with correct word
What part of the patient's record is commonly used to document specific patient variables, such as vital signs?
A) progress notes B) nursing notes C) critical paths D) graphic record
A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate?
a. "Are you having difficulty sleeping at night?" b. "How many calories a day do you con-sume?" c. "Do you have dry mouth or feel thirsty?" d. "How many times a day do you urinate?"