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 D
Explanation
A. "The healthcare provider will share this information with you" implies that the father has the right to access the client’s information, which is incorrect unless the client has provided explicit consent.
B. "I'm sorry, but your son's medical information is none of your business" is inappropriate and dismissive. While the father does not have automatic rights to the information, the response should be respectful and professional.
C. "I can give you those results as soon as I get them back from the lab" violates the client’s privacy, as the father is not automatically entitled to this information without the client’s consent.
D. "I can only give medical information to your son because he is an adult" is correct because the client is 19 years old and legally an adult. Under privacy laws such as HIPAA, the nurse cannot share medical information with anyone, including parents, unless the client has given permission.
Correct Answer is ["2.5"]
Explanation
Convert mcg to mg: 1 mg = 1000 mcg, so 125 mcg = 125/1000 = 0.125 mg
· Set up a proportion: (Desired dose / Concentration) = Volume to administer
0.125 mg / 0.05 mg/mL = X mL
· Solve for X: X = 2.5 mL
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