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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

The best way to evaluate the client’s understanding of self-care at home is to have the client demonstrate prescribed wound care.

This allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide feedback and clarification as needed.

Choice B, providing written instructions in the client’s native language, may be helpful but does not allow the nurse to directly evaluate the client’s understanding.

Choice C, asking the client if he/she understands after each instruction, may not be effective if the client is not comfortable expressing confusion or misunderstanding.

Choice D, having an interpreter repeat the wound care instructions, may be helpful but still does not allow for direct observation of the client’s ability to perform the necessary tasks.

A. Ask questions in a vague, nonspecific format. B. Get the most difficult questions over with first. C. Begin with questions that are less sensitive in nature. D. Share personal values to put the client at ease.

Correct Answer is C

Explanation

Nurses who provide end of life care are trained to communicate in a way that is concise, yet sensitive.

A personalized approach is often taken to meet the unique communication needs of each patient and to recognize when a person may be in pain or distressed 1.

Choice A is not the answer because asking questions in a vague, nonspecific format can lead to confusion and misunderstanding.

Choice B is not the answer because getting the most difficult questions over with first can be overwhelming for the client.

Choice D is not the answer because sharing personal values may not put the client at ease and may even make them feel uncomfortable.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

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?

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate. Which action should the nurse take to evaluate the client for urinary retention?

The nurse is caring for a patient one week post-surgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

Prior to performing digital removal of a fecal impaction, what is the most important assessment for the nurse to perform?

After a week of bed rest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. What should the nurse implement next?

Which response by the nurse is most therapeutic?

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?

A client receives a prescription for a one-time dose of metronidazole 2 grams by mouth. The medication is available in 500 mg tablets. How many tablets should the nurse administer? (Enter numerical value only).

After a long bed rest, a client with a Foley catheter and wrist restraints has repeatedly removed the antibiotic (G) tube and NG tube. At checking the restraints, which action is most important for the nurse to take?