On physical assessment of the skin of a patient, the nurse documents cyanosis. What other related assessment should the nurse perform?
A.
Ask the parent about yellow and orange vegetable intake.
B.
Draw blood for hemoglobin, hematocrit, and liver function studies.
C.
Palpate all the child's lymph nodes, assessing for enlargement.
D.
Take the child's vital signs, including blood pressure and pulse.
ANS: D
Cyanosis may indicate a compromised cardiorespiratory state, and the nurse should assess measures of cardiac output and respiratory function. Taking vital signs will give the nurse information about these two systems. Vegetable intake, laboratory studies (including liver function tests), and palpating lymph nodes are not related to cyanosis.
You might also like to view...
The nurse educator is preparing an in-service on pain management for the staff. One of the staff nurses asks, "What is the most important part of a pain assessment?" Which response by the nurse educator is the most appropriate?
1. "Pain is only partially subjective and primarily a physiologic experience, so vital signs are the most important assessment." 2. "A client's response to pain is always based on the underlying cause, so the client's admitting diagnosis is important." 3. "Vital signs are not reliable indicators of acute pain, because only some clients are able to elicit a change in blood pressure or pulse rate." 4. "The response to pain is unique and based on numerous factors, which need to be assessed."
Where did Florence Nightingale's original nursing education take place?
a. Saint Thomas b. Kings College Hospital c. Crimean Hospital d. Kaiserswerth School
The client with which conditions requires immediate nursing intervention? (Select all that apply.)
a. Shortness of breath b. Sternal retractions c. Pulse oximetry reading of 95% d. Occasional expiratory wheeze e. Respiratory rate of 8 breaths/min f. Arterial blood gas showing a pH of 7.35 g. Stridor
Which nursing intervention is appropriate for the patient diagnosed with heparin-induced thrombocytopenia who has the nursing diagnosis of Risk for Bleeding?
1. Avoid invasive procedures, such as rectal temperatures, urinary catheterizations, and parenteral injections. 2. Hold pressure on laboratory testing venipuncture sites for at least 15 mintues. 3. Give enemas to avoid straining during bowel movements. 4. Encourage frequent independent ambulation.