A client has a bluish tinge to the palms, soles, and conjunctivae. Based on these assessment data, what does the nurse do next?
a. Take a medication history.
b. Assess pulse oximetry.
c. Assess the client's personal hygiene.
d. Palpate the soles and palms.
B
Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin, cyanosis can be seen because the palms, soles, and conjunctivae have a bluish tinge. The nurse should as-sess for systemic oxygenation before continuing with other assessments.
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A nurse wants to perform a preliminary assessment for suicidal ideation in an older adult patient. Which question would obtain the desired data?
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a. Patient has not voided for the last 4 hours. b. Skin is dry with poor turgor on all extremities. c. Crackles are heard halfway up the posterior chest. d. Patient has had 5 loose stools over the last 6 hours.