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 C
Explanation
This will help determine if there is any residual urine left in the bladder after voiding.
Choice A is not the answer because reviewing the chart for the number of voids over the last 24 hours is important but not sufficient to evaluate for urinary retention.
Choice B is not the answer because evaluating for urinary incontinence is important but not sufficient to evaluate for urinary retention.
Choice D is not the answer because while palpating the suprapubic region for distention can provide some information, scanning the bladder after voiding is a more accurate way to evaluate for urinary retention.
Correct Answer is B
Explanation
While drying the client’s feet, the nurse should emphasize the need to thoroughly dry between the toes.
Moisture between the toes can create a breeding ground for bacteria and fungi, which can lead to infections such as athlete’s foot 1.
Choice C is not the answer because drying over the heels is not as important as drying between the toes 1.
Choice D is not the answer because drying around the ankles is not as important as drying between the toes 1.
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