A nurse is monitoring a client who is postoperative. Which of the following actions should the nurse take when collecting data about the client's respirations?

Count the client's respirations for 15 seconds.

Place the client in a supine position.

Inform the client when beginning to observe his respirations.

Observe the movements of the client's chest wall.

Answer and Explanation

The Correct Answer is D

A. "Count the client's respirations for 15 seconds" is incorrect. The nurse should count respirations for a full 60 seconds to ensure accuracy, especially in postoperative clients, as irregularities may be more easily detected with a longer observation period.

B. "Place the client in a supine position" is not necessary. While the position of the client can affect respiration, the nurse does not need to place the client in a supine position specifically to assess respirations. The client should be in a comfortable position that allows for adequate observation.

C. "Inform the client when beginning to observe his respirations" is incorrect. The client should not be aware that their respirations are being counted, as awareness can alter their breathing patterns and lead to inaccurate data.

D. "Observe the movements of the client's chest wall" is correct. Observing the chest wall allows the nurse to assess the rate, depth, and rhythm of respirations, as well as any signs of distress or abnormal patterns, which is crucial for monitoring postoperative respiratory status.

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Correct Answer is C

Explanation

A. "Eat 40 milligrams of protein-rich foods per day.": Protein intake is important during pregnancy, but 40 milligrams is an unusually low amount. The recommended amount is generally higher, around 71 grams of protein per day during pregnancy.

B. "Increase your dietary intake by 500 calories per day.": The general recommendation for calorie increase during pregnancy is about 300 calories per day, not 500. 500 calories per day may be recommended in specific situations, but it is not the typical guideline.

C. "Consume 600 micrograms of folic acid per day.": This is the correct recommendation. The CDC and other health guidelines recommend that pregnant individuals consume 400-600 micrograms of folic acid daily to prevent neural tube defects.

D. "Limit your caffeine intake to 700 milligrams per day.": Caffeine intake should generally be limited to around 200-300 milligrams per day during pregnancy, not 700 milligrams, as high caffeine intake can have adverse effects on pregnancy outcomes.

A. A client who has a sodium level of 140 mEq/L after one episode of diarrhea. B. A client who is 3 days postoperative following a hip arthroplasty and has a warm, red area on his left calf. C. A client who has atrial fibrillation and an INR of 4. D. A client who reports chest pain after ambulating.

Correct Answer is A

Explanation

A. "A client who has a sodium level of 140 mEq/L after one episode of diarrhea." This is the correct choice. A sodium level of 140 mEq/L is within the normal range, and the client has had only one episode of diarrhea, suggesting that they are stable and could be safely discharged.

B. "A client who is 3 days postoperative following a hip arthroplasty and has a warm, red area on his left calf." This is a concern. The warm, red area on the calf could indicate the presence of a deep vein thrombosis (DVT) or infection, both of which require further evaluation and management.

C. "A client who has atrial fibrillation and an INR of 4." This is concerning. An INR of 4 indicates an increased risk of bleeding, which requires closer monitoring and potentially adjusting the anticoagulation therapy before discharge.

D. "A client who reports chest pain after ambulating." This is an urgent issue that needs immediate attention. Chest pain could indicate a serious cardiac event, such as a myocardial infarction, and the client should not be discharged until further evaluation is performed.

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