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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The goal of the care plan should be to help the client overcome his activity intolerance related to pain.

This can be achieved by helping him to ambulate without discomfort.

Choice B is not the answer because taking analgesics as prescribed may help manage the pain but does not address the problem of activity intolerance.

Choice C is not the answer because showing evidence of incision healing is important but does not address the problem of activity intolerance.

Choice D is not the answer because avoiding pain-causing activity may help manage the pain but does not address the problem of activity intolerance.

A. Brushing an unconscious client's teeth should be avoided. B. Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client. C. Unconscious clients need less frequent mouth care than conscious clients. D. Positioning the unconscious client upright is the best method because they are not eating or drinking.

Correct Answer is B

Explanation

Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.

When mouth care is provided, an unconscious patient is placed in the side-lying position because this prevents secretions from pooling at the back of the oral cavity, lowering the risk of aspiration1.

Choice A is incorrect because brushing an unconscious client’s teeth should not be avoided.

In fact, it is recommended that you brush your teeth at least once every four hours1.

Choice C is incorrect because unconscious clients need regular mouth care just like conscious clients2.

Choice D is incorrect because positioning the unconscious client upright is not the best method.

Instead, they should be placed in a side-lying position to prevent aspiration1.

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The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is planning to provide mouth care to an unconscious client. Which statement is accurate for implementing mouth care to this client?

Correct Answer is B

Explanation

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