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The Nurse Is Collecting Data for a Patient Admitted for Heart

Question 13

Multiple Choice

The nurse is collecting data for a patient admitted for heart failure who has clavicle muscle retractions, nostril flaring, and labored breathing. Vital signs are as follows: blood pressure 162/84 mm Hg, pulse 120 beats/min, and respirations 32/min. Which patient data would require immediate action be taken?


A) Quiet, shallow respirations
B) Use of neck accessory muscles
C) Jaw jutting forward to inhale
D) Leaning on the over-bed table

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