A nurse caring for a patient on bed rest with a history of respiratory health problems should:

auscultate for bowel sounds once a shift.

auscultate lung sounds at the beginning of a shift.

monitor for skin turgor every shift.

monitor peripheral pulses once a shift.

Answer and Explanation

The Correct Answer is B

A.   Auscultating for bowel sounds once a shift is important but does not directly relate to the respiratory condition.
B.   Auscultating lung sounds at the beginning of a shift is a priority to assess for any signs of respiratory compromise or complications.
C.   Monitoring skin turgor every shift is important for hydration status but is less critical in comparison to lung sounds for a patient with respiratory problems.
D.   Monitoring peripheral pulses once a shift is important but does not address the respiratory condition directly.

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Correct Answer is D

Explanation

A. Temperature monitoring is important but not a top priority when a patient is receiving opiates unless there is suspicion of infection.
B. Pulse monitoring is also important but does not immediately indicate issues with opiate use.
C. Blood pressure is influenced by opiate use, but the primary concern is respiratory function due to the risk of respiratory depression.
D. Respirations should be closely monitored because opiates can significantly depress the respiratory system, leading to hypoventilation or respiratory arrest, which is the most critical risk.

A. Wrap the blood pressure cuff snugly around the arm. B. Center the cuff bladder over the brachial artery. C. Place the client's arm above the level of the heart. D. Check the instrument gauge to ensure the reading starts at zero

Correct Answer is C

Explanation

A. Wrapping the cuff snugly around the arm is important for an accurate reading. The cuff should be snug but not tight to avoid false readings.
B. Positioning the cuff bladder over the brachial artery ensures the correct placement for accurate measurement.
C. Placing the arm above the level of the heart can lead to a falsely low blood pressure reading. The arm should be at heart level for an accurate measurement.
D. Ensuring the gauge starts at zero is critical for accurate measurement and avoids errors in reading.

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A nurse caring for a patient on bed rest with a history of respiratory health problems should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is receiving an opiate-based medication to help mange pain. Which assessment has the highest priority when monitoring his condition?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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