A client whose skin has developed a bluish hue is diagnosed by ...

[future617RT]

A client whose skin has developed a bluish hue is diagnosed by the primary care provider as having cyanosis. What action should the nurse take in this case ?
 
  A) The nurse should give the client a tepid bath.
  B) The nurse should monitor for a sudden increase in temperature.
  C) The nurse should monitor the oxygen level in the client's bloodstream.
  D) The nurse should place a cool cloth on the client's forehead.

Question 2

A nurse is caring for a client in a healthcare facility. Which intervention should the nurse perform to measure the effectiveness of nursing care?
 
  A) Document observable evidence.
  B) Focus on the client's actual problem.
  C) Reassess the client's needs.
  D) Set goals for the client.

[blakcmamba]

Answer to Question 1

C
Feedback:
Cyanosis is a condition caused by hypoxia or lack of oxygen in the bloodstream. It can also occur because of hypothermia or a severe decrease in temperature. The nurse should monitor the oxygen level in the client's bloodstream and should also check the body temperature of a client who has developed cyanosis. A client with a fever, not cyanosis, should have a cool cloth placed on the forehead or given a tepid bath, so that the heat can be transferred by conduction.

Answer to Question 2

A
Feedback:
The nurse should provide observable evidence, which will help in indicating the effectiveness of nursing care given in any setting. Effective use of the nursing process enables the nurse to focus on not only actual, but also the client's potential problems; however, focusing on them will not allow the nurse to measure the effectiveness and success of the care plan. The client's needs are reassessed only if measurable and observable evidence is available. Setting goals for the client alone will not measure the effectiveness of the care plan. To measure the effectiveness, the nurse has to measure how successful the client has been in achieving the goals formulated for the client.