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

Measure oxygen saturation.

Determine pulse pressure.

Auscultate heart sounds.

Check for jugular vein distension.

Answer and Explanation

The Correct Answer is A

Choice A reason: Accessory neck muscle use indicates respiratory distress, likely from airway obstruction or lung disease, reducing oxygen delivery. Measuring oxygen saturation via pulse oximetry quantifies hypoxemia, critical for assessing alveolar gas exchange. Low saturation prompts immediate oxygen therapy, addressing the primary physiological threat of tissue hypoxia, making this the first action.

Choice B reason: Determining pulse pressure (systolic minus diastolic) assesses cardiovascular status but is less urgent than oxygen saturation. Accessory muscle use suggests respiratory compromise, impairing alveolar ventilation, not primarily a cardiac issue. Hypoxemia affects oxygen transport, requiring saturation measurement to guide intervention, making pulse pressure a secondary assessment.

Choice C reason: Auscultating heart sounds evaluates cardiac function but does not address respiratory distress. Accessory muscle use reflects increased respiratory effort, likely from hypoxia, affecting pulmonary gas exchange. Oxygen saturation directly measures oxygenation, guiding urgent therapy, while heart sounds are secondary unless cardiac failure is suspected, making this less immediate.

Choice D reason: Checking jugular vein distension assesses fluid overload, potentially linked to heart failure, but is not immediately relevant. Accessory muscle use primarily indicates respiratory distress, requiring oxygen saturation to confirm hypoxemia. Jugular distension is a supportive finding, but saturation measurement prioritizes addressing the acute oxygenation deficit, making it critical.

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Correct Answer is D

Explanation

Choice A reason: Applying a debriding agent is premature without confirming infection, as thick tan exudate may indicate pus. A wound culture identifies pathogens first, guiding treatment. Debridement risks unnecessary tissue damage if not indicated, per wound management and infection control protocols in surgical care.

Choice B reason: Removing sutures is inappropriate, as secondary intention wounds typically lack sutures, healing via granulation. Thick exudate suggests infection, requiring a culture first. Suture removal is irrelevant and risks delaying diagnosis, per principles of wound healing and infection assessment in secondary intention wounds.

Choice C reason: Applying steri-strips is unsuitable for secondary intention wounds, which heal openly without closure. Thick tan exudate warrants a culture to rule out infection before interventions. Steri-strips do not address potential infection, delaying appropriate care, per wound management and surgical nursing standards.

Choice D reason: Obtaining a wound culture is the priority, as thick tan exudate may indicate infection in a secondary intention wound. Identifying pathogens guides antibiotic therapy, preventing sepsis or delayed healing. This aligns with evidence-based wound assessment, ensuring timely and targeted treatment, per infection control and surgical care protocols.

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

Correct Answer is A

Explanation

Choice A reason: Varicella zoster virus (chickenpox) is highly contagious, spreading via airborne droplets and contact with lesions. A private room with contact and airborne precautions (N95 mask, negative pressure) prevents transmission to others. This isolates the virus, protecting immunocompromised patients, as varicella can cause severe complications, making this the correct assignment.

Choice B reason: A semiprivate room with contact precautions is insufficient, as varicella requires airborne precautions due to droplet nuclei transmission. Sharing a room, even with the same diagnosis, risks cross-infection if precautions fail. A private room ensures isolation, minimizing viral spread, making this option inadequate for infection control.

Choice C reason: A semiprivate room with airborne precautions is better but still risky, as sharing space increases transmission potential if precautions lapse. Varicella’s airborne spread requires a private room with negative pressure to contain droplet nuclei. A private room with both precautions ensures optimal isolation, making this option less safe.

Choice D reason: Standard and droplet precautions are inadequate for varicella, which requires airborne and contact precautions. Droplet precautions (surgical mask) do not protect against smaller airborne particles. A private room with full precautions prevents viral spread, as varicella can cause pneumonia in vulnerable patients, making this option incorrect.

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

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