how should the nurse assess for cyanosis in a client with dark skin who is in respiratory distress
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Nursing Elites

HESI LPN

Adult Health 2 Exam 1

1. How should the nurse assess for cyanosis in a client with dark skin who is in respiratory distress?

Correct answer: C

Rationale: Observing the lips and mucous membranes provides a reliable indicator of cyanosis in clients with dark skin tones. Choice A is incorrect because cyanosis can be assessed in clients with dark skin by observing other body areas. Choice B is incorrect as blanching the soles of the feet is not a relevant method for assessing cyanosis. Choice D is incorrect as cyanosis is not typically seen in the sclera in clients with dark skin.

2. The nurse is teaching a client about the administration of a subcutaneous injection. Which site is most appropriate for this type of injection?

Correct answer: D

Rationale: The abdomen is a common site for subcutaneous injections due to its accessibility and ample subcutaneous tissue. Subcutaneous injections are typically given in areas with a layer of fat between the skin and muscle, such as the abdomen, to allow for slow and consistent absorption of the medication. The deltoid muscle is more appropriate for intramuscular injections, not subcutaneous. The dorsogluteal muscle and ventrogluteal muscle are also more suited for intramuscular injections, not subcutaneous.

3. A client reports feeling isolated and lonely two weeks after the death of a spouse. What is the most appropriate nursing intervention?

Correct answer: D

Rationale: During the grieving process, individuals may benefit from various interventions to cope with their emotions and feelings of isolation. Encouraging the client to talk about the deceased spouse can provide an outlet for their emotions. Providing information on grief counseling can offer professional support tailored to their needs. Suggesting joining a support group can help the client connect with others who are going through a similar experience, fostering a sense of belonging and understanding. By selecting 'All of the above' as the correct answer, it acknowledges the importance of utilizing multiple strategies to support the client's emotional health and facilitate the grieving process effectively. The other options alone may not address all aspects of the client's needs during this difficult time.

4. The client is being taught about managing chronic kidney disease (CKD). Which dietary restriction should be emphasized the most?

Correct answer: B

Rationale: Restricting protein intake is vital in managing chronic kidney disease (CKD) as it helps decrease the kidneys' workload and slows down disease progression. High-fiber foods are generally beneficial for health and should not be limited in CKD management. Dairy products can be consumed moderately unless contraindicated. While adequate fluid intake is crucial, increasing intake excessively may not be suitable for all CKD patients, especially those with fluid restrictions. Therefore, the most crucial dietary restriction to emphasize in CKD management is restricting protein intake.

5. After morning dressing changes, a male client with paraplegia contaminates his ischial decubiti dressing with diarrheal stool. What is the best activity for the nurse to assign to the unlicensed assistive personnel (UAP)?

Correct answer: B

Rationale: The best activity for the nurse to assign to the unlicensed assistive personnel (UAP) in this situation is to provide perianal care and collect clean linens for the dressing change. This task is crucial to maintain proper hygiene, prevent infection, and promote healing in the areas affected by decubiti. Choice A is not the priority as addressing the contamination and ensuring hygiene is more critical. Choice C is not the immediate concern and does not address the current situation. Choice D involves direct client care tasks that should be handled by licensed nursing staff.

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