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
ANS: A
A. As the body is less able to compensate for decreased cardiac output, respirations will slow and become shallow. This patient is in serious difficulty and would need immediate treatment to survive. B, C, and D are signs of the body working to compensate and provide more oxygen.
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