While assessing a client, a nurse detects a bluish tinge to the ...

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While assessing a client, a nurse detects a bluish tinge to the client's palms, soles, and mucous membranes. Which action should the nurse take next?
 
  a. Ask the client about current medications he or she is taking.
  b. Use pulse oximetry to assess the client's oxygen saturation.
  c. Auscultate the client's lung fields for adventitious sounds.
  d. Palpate the client's bilateral radial and pedal pulses.

Question 2

A client with an infection has a fever. What actions by the nurse help increase the client's comfort? (Select all that apply.)
 
  a. Administer antipyretics around the clock.
  b. Change the client's gown and linens when damp.
  c. Offer cool fluids to the client frequently.
  d. Place ice bags in the armpits and groin.
  e. Provide a fan to help cool the client.

[lcapri7]

Answer to Question 1

ANS: 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 mucous membranes have a bluish tinge. The nurse should assess for systemic oxygenation before continuing with other assessments.

Answer to Question 2

ANS: B, C
Comfort measures appropriate for this client include offering frequent cool drinks, and changing linens or the gown when damp. Fever is a defense mechanism, and antipyretics should be administered only when the client is uncomfortable. Ice bags can help cool the client quickly but are not comfort measures. Fans are discouraged because they can disperse microbes.

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Excellent

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