The nurse is triaging a client and notes pallor and cyanosis of the oral cavity and lips. Based on this finding, the nurse would implement which of the following actions first?

Question

1. Administer IV fluids.
2. Provide oral hygiene.
3. Administer oxygen.
4. Provide a warm drink.

Answer 1

3
Rationale 1: 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.
Rationale 2: Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate hypoxia. Providing oral hygiene is not an appropriate intervention because it will not increase the client's oxygenation levels.
Rationale 3: Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate hypoxia. The nurse should apply oxygen for the client.
Rationale 4: Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate hypoxia. Providing a warm drink will not correct the client's oxygenation problem.