While observing a client’s face, which assessment finding requires immediate intervention by the nurse?
Cornea are jaundiced.
Face is flushed and diaphoretic.
Oral mucosa is cyanotic.
Eyelids are matted and crusted.
The Correct Answer is C
Choice A rationale
Jaundiced corneas indicate liver dysfunction or other serious conditions that require medical attention, but they do not require immediate intervention compared to cyanosis.
Choice B rationale
A flushed and diaphoretic face can indicate fever, heat exhaustion, or other conditions, but it is not as immediately life-threatening as cyanosis.
Choice C rationale
Cyanotic oral mucosa indicates a lack of oxygen in the blood, which is a medical emergency requiring immediate intervention.
Choice D rationale
Matted and crusted eyelids can indicate an eye infection or other conditions, but they do not require immediate intervention compared to cyanosis.
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Correct Answer is C
Explanation
Choice A rationale: Administering the prescribed morphine sulfate is important for managing the client’s severe pain. However, the priority action is to assess the neurovascular status of the affected limb to ensure there is no compromise
in circulation or nerve function.
Choice B rationale: Preparing the cast cart for immobilization is necessary to stabilize the fracture. However, before immobilization, it is crucial to perform a neurovascular assessment to identify any potential complications that may need
immediate attention.
Choice C rationale: Performing a neurovascular assessment of the right hand is the priority action. The client’s capillary refill time is prolonged (4 seconds), indicating potential compromised circulation. Assessing the neurovascular status will help determine if there is an urgent need for intervention to prevent further complications such as compartment
syndrome.
Choice D rationale: Initiating the IV infusion of 0.9% sodium chloride is important for maintaining hydration and ensuring venous access. However, the immediate priority is to assess the neurovascular status of the affected limb to identify any urgent issues that need to be addressed.
Correct Answer is C
Explanation
Choice A rationale
Jaundiced corneas indicate liver dysfunction or other serious conditions that require medical attention, but they do not require immediate intervention compared to cyanosis.
Choice B rationale
A flushed and diaphoretic face can indicate fever, heat exhaustion, or other conditions, but it is not as immediately life-threatening as cyanosis.
Choice C rationale
Cyanotic oral mucosa indicates a lack of oxygen in the blood, which is a medical emergency requiring immediate intervention.
Choice D rationale
Matted and crusted eyelids can indicate an eye infection or other conditions, but they do not require immediate intervention compared to cyanosis.