The nurse is performing a routine assessment on a dark-skinned client who has been admitted to the hospital. The nurse is assessing the client's oxygenation level and the presence of jaundice
Which statements indicate that the nurse is performing these specific assessments?
Select all that apply.
1. "I need to look at your eyes."
2. "Please open your mouth for me."
3. "Squeeze my fingers with your hands."
4. "I am going to listen to your belly with my stethoscope."
5. "I need to press on your fingernail."
Correct Answer: 1, 2, 5
The nurse should look into the dark-skinned client's eyes to examine the sclera for the presence of jaundice. The nurse can also examine the client's conjunctiva to assess for the presence of pallor and oxygenation status. The nurse should examine the inside of the client's mouth to assess the mucous membranes for the client's oxygenation status. The nurse can assess the client's capillary refill by pressing on the client's fingernails to determine the client's level of oxygenation. The nurse should assess the client's neurological status by asking the client to squeeze both of the nurse's hands bilaterally. The nurse should assess the client's bowel sounds during the gastrointestinal system assessment.
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