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. "Wash your hands after each administration of eye drops" is important but not specific to the safe administration of miotic eye drops. Washing hands before administration is more relevant to preventing infection.

B. "Squeeze your eye closed after administering the drops" can force the medication out of the eye, reducing its effectiveness. Instead, the client should be instructed to close the eye gently and apply pressure to the inner canthus to prevent systemic absorption.

C. "Do not allow the dropper bottle to touch the eye" is correct because it prevents contamination of the dropper, which could lead to eye infections.

D. "Administer the medication directly on the cornea" is incorrect because eye drops should be placed in the conjunctival sac, not directly on the cornea, to minimize irritation and maximize absorption.

A. Whether they contain pulp or fruit. B. The color and flavor of gelatin used. C. How many popsicles are available. D. If the popsicles are completely frozen.

Correct Answer is B

Explanation

A. Whether they contain pulp or fruit is unnecessary to assess because flavored gelatin is typically free of pulp or fruit. The concern lies more with the appropriateness of the ingredients as clear liquids.

B. The color and flavor of gelatin used is the correct response because some colored gelatins (e.g., red or purple) can mimic blood if vomiting occurs, potentially leading to misinterpretation of the child’s condition. The nurse should ensure that the parent uses neutral or light-colored gelatin (e.g., yellow or clear).

C. How many popsicles are available is not relevant to the appropriateness of the popsicles as a clear liquid or their potential effects on the child’s condition.

D. If the popsicles are completely frozen is not significant as long as the popsicles are made from appropriate clear liquids.

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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

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