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. "Tell me about the visit with your significant other.". B. "I can see that you are feeling lonely.". C. "Would you like to talk for a while?". D. "What did you enjoy about your visit tonight?".

Correct Answer is C

Explanation

This response shows that the nurse is willing to listen and provide support to the client.

It also allows the client to decide if they want to talk and share their feelings.

Choice A is not correct because it is not the most therapeutic response.

While it does encourage the client to talk about their visit with their significant other, it does not show that the nurse is willing to listen and provide support.

Choice B is not correct because it is not the most therapeutic response.

While it does acknowledge that the client may be feeling lonely, it does not show that the nurse is willing to listen and provide support.

Choice D is not correct because it is not the most therapeutic response.

While it does encourage the client to talk about their visit, it does not show that the nurse is willing to listen and provide support.

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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

Which response by the nurse is most therapeutic?

Correct Answer is C

Explanation

Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).

While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A client who had emergency gallbladder surgery yesterday is getting ready to be discharged. The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago. Which intervention should the nurse implement next?

Which of the following responses would be the most therapeutic when communicating with a client who has recently had a visit from their significant other and is displaying changes in behavior?

The nurse is caring for a client who has only months predicted to live. The client avoids questions regarding plans for care. What is the next approach for the nurse to use when discussing end of life issues with the client?

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which of the following is most useful for the nurse to include?