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 A

Explanation

A. The client will adhere to the medication regimen after discharge is an appropriate outcome statement because it is specific to the client's need to manage hyperglycemia with insulin therapy postoperatively. This outcome addresses the necessity of learning self-injection techniques and adhering to the prescribed regimen.

B. The client attempts to self-administer insulin but is unable to perform injection is not an appropriate outcome statement because it does not reflect a desired or achievable goal. It implies failure rather than a measurable improvement.

C. The client will demonstrate ability to change the ostomy bag in two days is relevant to the colostomy care but does not address the immediate need for managing hyperglycemia with insulin therapy.

D. The client's breath sounds will be auscultated by the nurse every 4 hours is a task-oriented intervention rather than a client-centered outcome statement.

A. After each instruction, ask if the client understands. B. Provide written instructions in the client's native language. C. Have the client demonstrate prescribed wound care. D. Have an interpreter repeat the wound care instructions.

Correct Answer is C

Explanation

A. After each instruction, ask if the client understands is not the most reliable method because the client may answer affirmatively out of politeness or lack of comprehension.

B. Provide written instructions in the client's native language is helpful as a supplementary teaching tool but does not evaluate the client's understanding or ability to perform wound care.

C. Have the client demonstrate prescribed wound care is the most effective method because it allows the nurse to directly observe the client’s technique and understanding, ensuring they can perform the task correctly at home.

D. Have an interpreter repeat the wound care instructions ensures accurate communication but does not assess whether the client can perform the care independently.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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