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 B

Explanation

A. Clamping the urinary catheter prior to the collection is typically done with clean hands, as the nurse is preparing the catheter for specimen collection. Gloves are not required for this step, as long as proper hand hygiene is performed before and after.

B. Using the syringe to remove the specimen from the catheter is the correct time for the nurse to wear gloves. This step involves direct contact with potentially contaminated urine, and gloves are necessary to maintain infection control and protect the nurse from exposure to bodily fluids.

C. Recording the output on the flowsheet in the client's room does not require gloves, as this step does not involve direct contact with the urine. The nurse should perform proper hand hygiene before and after documenting the output.

D. Transporting the urine specimen to the laboratory does not require gloves, as the specimen is contained in a biohazard bag. Gloves are typically worn during the collection process, but transporting a properly sealed specimen does not require additional protection.

A. A private room with both contact and airborne precautions. B. A semiprivate room with a roommate who has the same diagnosis and airborne precautions. C. A private room with both standard and droplet precautions. D. A semiprivate room with a roommate who has the same diagnosis and contact precautions.

Correct Answer is A

Explanation

A. A private room with both contact and airborne precautions is appropriate for a client with varicella zoster virus (chickenpox or shingles in an immunocompromised state). This virus can spread through direct contact with lesions and airborne transmission of respiratory droplets.

B. A semiprivate room with a roommate who has the same diagnosis and airborne precautions could be considered if the roommate also has the same strain of the virus, but a private room is generally preferred to minimize cross-contamination risks.

C. A private room with both standard and droplet precautions is insufficient. Airborne precautions are necessary because varicella zoster virus can spread via airborne routes.

D. A semiprivate room with a roommate who has the same diagnosis and contact precautions does not account for the airborne transmission risk, making this option inappropriate.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

Correct Answer is B

Explanation

A client is being admitted to the unit with a varicella zoster virus infection. Which room should the charge nurse assign to the client?

Correct Answer is A

Explanation

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