The nurse is triaging a client and notes pallor and cyanosis of ...

[burchfield96]

The nurse is triaging a client and notes pallor and cyanosis of the oral cavity and lips. Which action by the nurse is the priority based on the assessment data?
 
  1. Administer IV fluids.
  2. Provide oral hygiene.
  3. Administer oxygen.
  4. Provide a warm drink.

Question 2

A client arrives in the emergency department with complaints of intermittent nosebleeds over the past two days. Which are priority assessments for the nurse to implement when providing care to this client?
 
  Select all that apply.
  1. Request information from the client regarding increased propensity for bruising or bleeding.
  2. Assess the tonsils for redness or swelling.
  3. Obtain a blood pressure.
  4. Check for deviated septum.
  5. Request information from the client to determine if there was any recent thin, watery drainage from the nose.

[sierramartinez]

Answer to Question 1

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

Answer to Question 2

Correct Answer: 1, 3, 5
The client may have a blood coagulation disorder that may result in increased bruising or bleeding. This disorder may have produced the episodes of epistaxis. Hypertension is a contributory factor to the occurrence of nosebleeds. The nurse should assess the client's blood pressure to determine if it is elevated. Thin, watery drainage from the nose is associated with rhinitis. Rhinitis is associated with epistaxis. Red, swollen tonsils are associated with tonsillitis. Tonsillitis is not associated with epistaxis. A deviated septum is not associated with epistaxis.