63. The nurse aide will FIRST respond to a client who is:
Answer: B
The nurse aide will FIRST respond to a client who is sitting quietly with blue lips.
In a medical emergency, a client exhibiting signs of cyanosis, such as blue lips, indicates a significant lack of oxygen and requires immediate attention. Therefore, the nurse aide must prioritize this situation over others.
A) Wanting to go to the toilet
While this request is important for the client's comfort and hygiene, it does not indicate an immediate life-threatening situation. The urgency of bathroom needs is less critical compared to a client showing signs of hypoxia or oxygen deprivation.
B) Sitting quietly with blue lips
This option is correct as it signals a potentially severe medical condition requiring prompt intervention. Cyanosis is a clear indication that the client's oxygen levels are critically low, and any delay in addressing this could lead to serious complications.
C) Coughing with a reddish face
Coughing can be a sign of various conditions, but a reddish face typically does not indicate a life-threatening issue. While coughing warrants attention, it is not as urgent as the signs of cyanosis presented in option B.
D) Attempting to stand from a wheelchair
While this indicates a need for assistance and potential risk of falling, it does not represent an immediate medical emergency. The priority should be to address life-threatening conditions, such as those indicated by cyanosis.
Conclusion
Responding to a client with blue lips is crucial due to the direct threat to their oxygenation and overall safety. Other options may require attention but do not pose the same immediate risk to the client's health. Thus, prioritizing the client with cyanosis is essential in a nursing context.