A black client with asthma seeks emergency care for acute respiratory distress. Because of this client’s dark skin, the nurse should assess for cyanosis by inspecting the:
A. Lips
B. Mucous membranes
C. Nail beds
D. Earlobes
Correct Answer: B. Mucous membranes
Skin color doesn’t affect the mucous membranes. When the oxygen level has dropped only a small amount, cyanosis may be hard to detect. In dark-skinned people, cyanosis may be easier to see in the mucous membranes (lips, gums, around the eyes) and nails. The lips, nail beds, and earlobes are less reliable indicators of cyanosis because they’re affected by skin color.
Option A: Red blood cells provide oxygen to body tissues. Most of the time, nearly all red blood cells in the arteries carry a full supply of oxygen. These blood cells are bright red and the skin is pinkish or red. Blood that has lost its oxygen is dark bluish-red. People whose blood is low in oxygen tend to have a bluish color to their skin. This condition is called cyanosis.
Option C: But in dark-skinned patients, cyanosis may present as gray or whitish (not bluish) skin around the mouth, and the conjunctivae may appear gray or bluish. When assessing a patient’s skin, use natural light or a halogen lamp rather than fluorescent light, which may alter the skin’s true color and give the illusion of a bluish tint.
Option D: Skin color is particularly important in detecting cyanosis and staging pressure ulcers. Cyanosis occurs when a person has 5 g/dL of unoxygenated hemoglobin in the arterial blood. Central cyanosis (cyanosis of the lips, mucous membranes, and tongue) occurs when arterial oxygen saturation falls below 85% in patients with normal hemoglobin levels.
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