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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is B
Explanation
A. Apply sterile-strips is not the most appropriate action. Steri-strips are typically used for approximating wound edges or supporting sutures, but they are not the first intervention when there is concern about infection or unusual exudate.
B. Obtain a wound culture is the correct action. A thick tan exudate may indicate infection or an abnormal healing process. The nurse should obtain a wound culture to identify the presence of infection and guide appropriate treatment.
C. Apply a debriding agent is premature without first assessing the wound for infection. Debridement is typically used to remove necrotic tissue, but the priority is to determine whether an infection is present before proceeding with debridement.
D. Remove every other suture is not indicated. Sutures should not be removed unless instructed by the healthcare provider, and there is no indication that sutures need to be removed at this time. The focus should be on assessing the wound for infection first.
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