It is suspected that the client’s oxygenation status is deteriorating.

It is suspected that the client’s oxygenation status is deteriorating. The nurse is aware that the abnormal assessment finding that represents the most serious indication of the client’s decreased oxygenation is:

1. Poor skin turgor
2. Clubbing of the nails
3. Central cyanosis
4. Pursed-lip breathing

ANSWER

ANS: 3
Central cyanosis is the most serious finding because it indicates hypoxemia. Poor skin turgor in-dicates dehydration. It is not an indication of the client’s decreased oxygenation. Clubbing of the nails is found in clients with prolonged oxygen deficiency, endocarditis, and congenital heart defects. It is a change that occurs over time and is not an indication of the client’s current deteri-oration in oxygenation status. Pursed-lip breathing is used to slow expiratory flow. It is not the most serious indication of a client’s decreased oxygenation.