A nurse is caring for a client who has fallen while getting out of bed and states, “I’m okay! I guess I should have called for help to the bathroom.” After assessing the client, the nurse notifies the provider.

Which of the following documentation should the nurse include in the client’s medical record?

A. Place the client in semi-Fowler’s position:

While the semi-Fowler's position can be helpful in assessing respiratory function, it is not specifically required for measuring the respiratory rate. The key is to ensure the client is comfortable and able to breathe easily.

B. Have the client rest an arm across the abdomen:

Placing the arm across the abdomen is not a standard practice for measuring respiratory rate. The key is to allow the client to breathe naturally, and this position is not necessary for accurate measurement.

C. Observe one full respiratory cycle before counting the rate:

This ensures that the count is accurate and reflective of the client's typical breathing pattern.

D. Count the rate for 30 seconds if it is irregular:

When measuring the respiratory rate, it is generally recommended to count for a full minute to obtain an accurate representation of the client's breathing pattern. Counting for 30 seconds may underestimate or overestimate the rate, especially if the irregularity is not consistent.

E. Count and report any sighs the client demonstrates:

Sighs can be indicative of emotional or physiological stress, and noting them is important for a comprehensive respiratory assessment.

A. Wait 30 min and return to measure the oral temperature:

Waiting 30 minutes may not be necessary. It's more practical to take immediate steps to address potential factors affecting the reading.

B. Provide the client a sip of warm water, wait 5 min, and measure the temperature:

This can be a reasonable and practical approach to stimulate blood flow in the oral cavity and achieve a more accurate oral temperature reading.

C. Document that the nurse was unable to measure the client’s temperature:

Before documenting an inability to measure the temperature, the nurse should attempt appropriate interventions, such as warming the oral cavity or using an alternate route

D. Determine if the client has eaten or drank within the last 15 minutes:

Eating or drinking something cold shortly before taking an oral temperature can result in a lower reading. Checking for recent intake is important to ensure the accuracy of the measurement.

E. Use an alternate route (i.e., axillary, rectal) to take the client’s temperature:

If the oral temperature reading remains difficult to obtain or is not reliable, using an alternate route may be necessary. However, this depends on the client's condition, the reason for the temperature measurement, and the healthcare facility's protocols.