The finding during a routine assessment that would most strongly suggest to the nurse the presence of serious heart or lung disease is
A) blanching of nail beds when compressed.
B) broken vessels in the legs.
C) duskiness of the buccal mucosa.
D) pulse rate greater than 90 beats/min.

Question

Quizplus · Accepted Answer

The nurse should observe the skin and mucous membranes for abnormalities such as central or peripheral cyanosis. The presence of a bluish tinge or duskiness is indicative of central cyanosis. Central cyanosis implies serious heart or lung disease because impaired physiologic functioning is leading to decreased arterial oxygen saturation. Peripheral cyanosis, seen in lips, ear lobes, and nail beds, suggests peripheral vasoconstriction.

The Finding During a Routine Assessment That Would Most Strongly