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.

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Correct Answer is C

Explanation

Restate the vital importance of performing hand hygiene. The most effective way to prevent MRSA is frequent hand washing1.

Choice A is incorrect because changing the coccyx dressing after performing routine care does not necessarily prevent the spread of MRSA to others.

Choice B is incorrect because changing the coccyx dressing before performing routine care does not necessarily prevent the spread of MRSA to others.

Choice D is incorrect because performing a coccyx dressing change in the nursing station does not necessarily prevent the spread of MRSA to others.

A. Tap the feet forwards and backwards. B. Bend the arm by flexing the ulna to the humerus. C. Turn the head to the right and left. D. Extend the arm at the side and rotate in circles.

Correct Answer is B

Explanation

To exercise the hinge joints, the nurse should instruct the client to bend the arm by flexing the ulna to the humerus.

Hinge joints allow for movement in one direction, like a door hinge. The elbow joint is an example of a hinge joint.

Choice A is not the answer because tapping the feet forwards and backwards exercises the ankle joint, which is not a hinge joint.

Choice C is not the answer because turning the head to the right and left exercises the pivot joint in the neck, which is not a hinge joint.

Choice D is not the answer because extending the arm at the side and rotating in circles exercises the ball-and-socket joint in the shoulder, which is not a hinge joint.

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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 is in contact isolation due to a stage IV coccyx wound infected with MRSA. The nurse plans interventions to prevent multiple infections. Which intervention is most appropriate to prevent the spread of MRSA to others?

Correct Answer is C

Explanation

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

Correct Answer is B

Explanation

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