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 C

Explanation

The most important intervention the nurse should take when administering these medications to the client is to assess the client’s pain level and administer the appropriate medication based on the level of pain.

Choice A is not the correct answer because administering all medications at the same time may not provide effective pain relief and could result in overmedication.

Choice B is not the correct answer because administering the medication with the highest dose first may not provide effective pain relief and could result in overmedication.

Choice D is not the correct answer because administering the medication with the longest duration of action first may not provide immediate pain relief.

A. Inject in abdominal area at least 2 inches from the umbilicus. B. Rotate injections between the abdomen and gluteal areas. C. Massage the injection site to increase absorption. D. Expel the air in the prefilled syringe prior to injection.

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

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