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

Guided imagery involves creating a specific imagined reality for yourself.

These techniques can be self-taught or guided by a professional.

The more you’re able to use your imagination and engage your senses, the greater the benefits 1.

Choice B is not the answer because motivational phrases may not be as effective as positive external places in reducing chronic pain through guided imagery.

Choice C is not the answer because tranquil sounds may not be as effective as positive external places in reducing chronic pain through guided imagery.

Choice D is not the answer because emotional reflection may not be as effective as positive external places in reducing chronic pain through guided imagery.

A. Ask the client to describe the pain. B. Provide a numeric pain scale. C. Identify effective pain relief measures. D. Observe body language and movement.

Correct Answer is B

Explanation

The assessment of pain intensity by a validated pain scale is a critical initial step, and a patient’s self-reporting is widely considered as the key to effective pain management 1.

According to good practice guidelines, clinicians must accept a patient’s statement, regardless of their own opinions 1.

Choice A is not the answer because asking the client to describe the pain does not provide an objective measure of pain intensity 1.

Choice C is not the answer because identifying effective pain relief measures does not assess the intensity of the client’s pain 1.

Choice D is not the answer because observing body language and movement does not provide an objective measure of pain intensity 1.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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