The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?
Blood pressure.
Respiratory rate.
Temperature.
Pulse rate.
The Correct Answer is B
If a nurse observes that a client is using accessory muscles, it indicates an obstruction of the airways, which reduces oxygen saturation.
Accessory muscles help in the act of forced expiration to wash out carbon dioxide and improve oxygen saturation 1.
Therefore, the nurse should obtain the respiratory rate first.
Choice A is not the answer because determining pulse pressure will not provide any significant indication of respiratory distress 1.
Choice C is not the answer because temperature does not provide any significant data about the use of accessory muscles in respiration 1.
Choice D is not the answer because pulse rate does not provide any significant data about the use of accessory muscles in respiration 1.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Charting by exception means that the nurse only documents findings that deviate from the established norm or expected outcome.
In this case, the nurse should document the assessment that is not within normal limits, which is “Basilar lung sounds that are diminished in the left lung.”
Choice B is not the answer because contraction of the left pupil when light shines in the right eye is a normal finding known as consensual pupillary response.
Choice C is not the answer because capillary refill of 2 seconds in the lower right foot is a normal finding.
Choice D is not the answer because active bowel sounds in the lower right quadrant are a normal finding.
Correct Answer is A
Explanation
Inject in abdominal area at least 2 inches from the umbilicus.
When administering subcutaneous heparin injections, it is important to choose an injection site on either your tummy or outer areas of your left or right thigh.
Your tummy is usually best as the injection site and it is important that you change the site each time 1.
The heparin needs to go into the fat layer under the skin 2.
Choice B is incorrect because injections should not be rotated between the abdomen and gluteal areas.
Choice C is incorrect because massaging the injection site is not recommended.
Choice D is incorrect because air bubbles in a pre-filled syringe should not be expelled prior to injection 2.
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