Try Naxlex NCLEX-RN (Free-Trial)

A nurse is instructing a group of nursing students in taking vital signs and assessing a client's respiratory status.
Which of the following guidelines should the nurse include? Select all that apply.

Act as if you are still taking the radial pulse while assessing respiratory rate so the client does not know you are counting.

If the respiratory rate is regular, count for 30 seconds and multiply by 2.

Observe the depth and rhythm of the respirations.

Count a full respiratory cycle (inhalation and exhalation)

Answer and Explanation

Correct Answer : B,C,D

The correct answer is choices B, C, and D.

When assessing respiratory rate, it is important to count for a full respiratory cycle, which includes both inhalation and exhalation. If the respiratory rate is regular, the nurse can count for 30 seconds and multiply by 2 to obtain the total number of breaths per minute. The nurse should also observe the depth and rhythm of the respirations, noting any abnormalities or changes. It is not recommended to pretend to take the radial pulse while assessing respiratory rate, as this can lead to inaccurate readings and is not a professional approach to care

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

The correct answer is choice B, High Fowler's position. The High Fowler's position is the optimal position for nasogastric tube insertion as it allows for easy visualization and access to the nasal cavity, pharynx, and esophagus. The client should be in a semi-sitting position with the head of the bed elevated to at least 45-60 degrees. This position allows for better visualization and easier passage of the nasogastric tube through the nasal passages and into the esophagus. The other positions listed do not provide the optimal positioning for nasogastric tube insertion.

A. Abdominal sounds and colonoscopy. B. Bowel sounds and obtain a stool specimen. C. Abdominal inspection and kidney, bowel, and ureter x-ray. D. Bowel palpation and abdominal x-ray.

Correct Answer is B

Explanation

The correct answer is choice B: Bowel sounds and obtain a stool specimen.

When a client presents with abdominal cramping and persistent diarrhea, obtaining a stool specimen is the first priority to determine the cause of the diarrhea. The stool specimen can be sent to the laboratory for analysis to check for the presence of bacteria, viruses, or parasites. The nurse should also assess bowel sounds as part of the client's abdominal assessment to monitor for any changes in bowel motility. The other options listed are not the first priority in this situation and may be ordered after the cause of the diarrhea has been determined.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is instructing a group of nursing students in taking vital signs and assessing a client's respiratory status. Which of the following guidelines should the nurse include? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

A patient has an order for Normal Saline 1000 mL to infuse over 3 hours. The medication will be infused with an IV pump. How many mL/h should the IV pump be programmed for?

A nurse is taking action and performing interventions in the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step in the nursing process? Select all that apply.

A nurse is beginning a complete bed bath for a client. After preparing the client by removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first?

A new patient is admitted to a medical unit with Clostridium difficile (C-diff). Which type of precautions or isolation should the nurse apply for this patient?

A nurse can most accurately assess a client's apical heart rate by which of the following methods?

The nurse performed an assessment on a patient's upper extremities. All findings were within normal limits. Which reflects the most accurate and complete terminology used when documenting these normal results?

A patient is on a PCA pump following an abdominal surgery. The order states the client can have 0.5mg morphine every 15 minutes as needed. The client pushed the button 10 times in the past 60 minutes. How many doses did the client receive?

A nurse caring for a post-operative client observes the drainage in the client's closed wound drainage system. The drainage is dark red in color. The nurse documents the drainage as which of the following?

A nurse is instructing a group of nursing students in taking vital signs and assessing a client's respiratory status.
Which of the following guidelines should the nurse include? Select all that apply.