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
The priority intervention for a patient with persistent STIs and risky behaviors is to recommend consistent use of latex condoms.
According to the USPSTF, behavioral counseling is recommended for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs)1.
This includes providing information on common STIs and STI transmission, aiming to increase motivation or commitment to safer sex practices, and providing training in condom use1.
Choice B is not the answer because annual infection screening is important but not the priority intervention.
Choice C is not the answer because while it’s true that some infections may have no initial symptoms, this is not a priority intervention.
Choice D is not the answer because while advising that alcohol intake may lead to risky behaviors is important, it’s not the priority intervention.
Correct Answer is C
Explanation
Antibiotics can have side effects that may contribute to fatigue and difficulty sleeping.
Choice A is not the correct answer because reading a book about how to sleep better is not a contributing factor to fatigue and difficulty sleeping.
Choice B is not the correct answer because exercising in the morning and afternoon can actually help improve sleep.
Choice D is not the correct answer because sleeping between 10 PM and 9 AM each night is a normal sleep schedule and should not contribute to fatigue and difficulty sleeping.
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