A nurse is instructing a group of nursing students in measuring a client’s respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply)

Place the client in semi-Fowler’s position

Have the client rest an arm across the abdomen

Observe one full respiratory cycle before counting the rate

count the rate for 30 sec if it is irregular

Count and report any sighs the client demonstrates

Answer and Explanation

Correct Answer : C,E

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.

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Correct Answer is C

Explanation

A. Assess the pedal pulses with a Doppler device:

Assessing the pedal pulses with a Doppler device may be useful in certain situations, but when the radial pulse is irregular, it's more important to assess the central (apical) pulse to get a more accurate representation of the heart's rhythm.

B. Assess the apical pulse with a Doppler device:

While using a Doppler device on the apical pulse is an option, it's generally not the first choice when assessing irregular pulses. The apical pulse can often be palpated manually, and it's more practical to assess it directly for irregularities.

C. Assess the apical pulse for a full minute:

This is the recommended action when the radial pulse is irregular. By assessing the apical pulse for a full minute, the nurse can accurately determine the heart rate and identify any irregularities in rhythm, providing a comprehensive assessment of the cardiac status.

D. Assess the pedal pulses for a full minute:

While assessing the pedal pulses is important in certain situations, it may not be the priority when dealing with an irregular radial pulse. Assessing the apical pulse for a full minute gives a more direct and accurate reflection of the heart's rhythm.

Correct Answer is ["0.7"]

Explanation

To calculate the amount of hydroxyzine (Vistaril) to administer, use the formula:

D (desired dose) / H (have dose) x Q (quantity) = X (amount to give)

In this case, D = 35 mg, H = 50 mg/mL, and Q = 1 mL. Plug in the values and solve for X:

35 mg / 50 mg/mL x 1 mL = 0.7 mL

Therefore, the amount of hydroxyzine (Vistaril) to administer is 0.7 mL.

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A nurse is instructing a group of nursing students in measuring a client’s respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client’s radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

Ordered: Hydroxyzine (Vistaril) 35 mg IM stat Available: Hydroxyzine (Vistaril) 50 mg/mL Administer: ____ ml

Correct Answer is ["0.7"]

Explanation

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