The nurse assesses the client with light skin and observes normally shaped nail beds exhibiting pallor and slight bluishness. Which should the nurse implement?
1. Provide a warm heating pad.
2. Collaborate with the physician.
3. Assess client oxygen saturation.
4. Check for restricted venous return.
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3. Nail beds in a client with light skin are a view of the client's capillary bed at the periphery. Pallor and bluishness in the capillary bed indicate inadequate oxygenation because oxygenated blood is dark red, rendering the nail beds pink. Hypoxia in ex-tremities can be due to cold temperatures; vasoconstriction, peripheral vascular, or vasospastic disease reducing the oxygenated blood flow; hypoxemia; anemia; prepa-ration for dying; and respiratory failure.
1. Generally, heat and cold require a provider prescription; moreover, the nurse needs to assess the client and to gather related data before being able to decide that warmth is indicated.
2. The nurse needs to complete the assessment, first, as long as the client is in no immediate danger or experiencing distress, and to think critically before collaboration. If collaboration with the provider becomes necessary, the nurse presents a complete client assessment.
4. Restricted venous return usually leads to edema; severe peripheral edema lead to pallor and cyanosis potentially occurring but it is not common.
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