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
Correct Answer:
Verified
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