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. Assess the client for signs of diminished circulation in the hands is unnecessary at this stage, as the primary concern is ensuring proper crutch fit and teaching safe use.

B. Proceed with teaching the client how to walk with the crutches is correct because a space of three finger-widths between the crutch and the axilla indicates proper crutch height. This prevents nerve damage and discomfort in the axilla.

C. Ask the client to sit down while the crutch length is adjusted is not needed since the crutches are already appropriately adjusted based on the observed spacing.

D. Confer with the physical therapist for correct crutch size is unnecessary because the nurse can confirm that the crutches are properly fitted based on standard guidelines.

A. Self-care deficit. B. Risk for infection. C. Impaired physical mobility. D. Risk for impaired skin integrity.

Correct Answer is D

Explanation

A. Self-care deficit might apply if the client is unable to perform foot care independently. However, the priority concern is addressing the potential complications of neuropathy, such as skin breakdown, before considering assistance with care.

B. Risk for infection is a valid concern, especially if skin integrity is compromised. However, infection prevention depends on maintaining intact skin, making skin integrity the more immediate priority.

C. Impaired physical mobility may contribute to challenges in foot care but does not directly address the risk posed by neuropathy, which primarily affects sensory perception and increases vulnerability to unnoticed injuries.

D. Risk for impaired skin integrity is the priority because neuropathy reduces sensation in the feet, increasing the likelihood of unnoticed injuries, pressure sores, or burns. Early identification and prevention of skin damage are essential for avoiding complications.

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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

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger-widths between the top of the crutch and the client's axilla. Which action should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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