Difficulty: Medium
Average Score: 87%
Simulated
The nurse is caring for a client with sepsis. Which intervention would the nurse include to monitor for decreased tissue perfusion?
Correct answer
C
Rationale
Monitoring for cyanosis is a direct method to assess tissue perfusion. Cyanosis, a bluish discoloration of the skin, indicates poor oxygenation and is a sign of decreased tissue perfusion.