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 C

Explanation

A. Select upper arm as the injection site is incorrect. While the upper arm can be an appropriate site for an intradermal injection, the most common site for ID injections is the inner forearm. The choice of site depends on the procedure and provider's preferences.

B. Massage the site gently after injection is incorrect. Massaging the site after an intradermal injection can disrupt the injection, causing the medication to be dispersed under the skin rather than remaining in the dermis.

C. Ensure bevel of the needle is pointing up is the correct action. For intradermal injections, the bevel of the needle should be facing upward to ensure that the medication is injected just beneath the skin, creating a visible wheal.

D. Hold the syringe perpendicular to the skin is incorrect. For intradermal injections, the needle should be inserted at a 5-15 degree angle to the skin, not perpendicular.

A. Don gloves. B. Apply a surgical mask. C. Put on an isolation gown. D. Wash hands.

Correct Answer is D,C,B,A

Explanation

Correct order: D C B A

Washing hands is the first step before any PPE is applied to ensure cleanliness and prevent the introduction of pathogens.
Putting on the isolation gown is the next step, as it protects the nurse's clothing from exposure to potentially infectious materials.
Applying a surgical mask is the next step to protect the nurse from airborne or droplet transmission.
Donning gloves is the final step, as gloves should be put on last to protect the hands while providing direct care, especially when dealing with wound care.

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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 is administering an intradermal (ID) injection to a client. Which action should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is D,C,B,A

Explanation

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