While measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. Which follow-up action should the nurse take first?

Check for neck vein distention.

Auscultate heart sounds.

Measure oxygen saturation.

Determine pulse pressure.

Answer and Explanation

The Correct Answer is C

A. Check for neck vein distention is important for assessing cardiovascular status, but it is not the first priority when accessory muscle use indicates potential respiratory distress.

B. Auscultate heart sounds is a useful assessment for cardiac issues but does not directly address the immediate concern of respiratory effort and oxygenation.

C. Measure oxygen saturation is the first priority because accessory muscle use suggests increased respiratory effort, which may indicate hypoxemia. Measuring oxygen saturation provides immediate information about the client’s oxygenation status and guides further interventions.

D. Determine pulse pressure is not directly relevant to the observation of accessory muscle use and would not address the immediate respiratory concern.

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Correct Answer is A

Explanation

A. Obtain the specimen from the client's current bowel movement is the correct action. Occult blood can be present even in normal-appearing stool. The nurse should obtain the specimen from the current bowel movement, as it is part of the protocol for testing for hidden blood in the stool. The stool does not need to be tarry or black to test for occult blood.

B. Withhold specimen collection until tarry black stool is observed is incorrect. Tarry black stools often indicate the presence of digested blood, but occult blood testing is designed to detect blood that may not be visible to the naked eye, even in normal-colored stool.

C. Contact the healthcare provider before obtaining the specimen is unnecessary. The nurse can proceed with the collection as per the standard procedure without needing to contact the healthcare provider, unless there is a specific reason to do so.

D. Wait to obtain the specimen until observable blood is present is incorrect. The purpose of an occult blood test is to detect hidden (occult) blood, which may not be visible to the eye. The nurse should not wait for visible blood to appear before collecting the specimen.

A. Verify client's identification by scanning the barcode on the armband. B. Reconcile the medication to be administered with the initial client prescription. C. Remove the medication from the unit dose packaging while verifying the dose. D. Scan the medication barcode to document administration on the eMAR.

Correct Answer is A

Explanation

A. Verify client's identification by scanning the barcode on the armband is correct because verifying the client’s identity is the next step after accessing the eMAR. This ensures that the right medication is given to the right client, following the “rights” of medication administration.

B. Reconcile the medication to be administered with the initial client prescription is important but should already have been completed during the medication preparation and verification process.

C. Remove the medication from the unit dose packaging while verifying the dose is part of the preparation process but occurs after confirming the client’s identity.

D. Scan the medication barcode to document administration on the eMAR is done after verifying the client’s identity and ensuring the medication is correct. It is not the immediate next step after logging into the eMAR.

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While measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. Which follow-up action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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