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.
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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Related Questions
Correct Answer is C
Explanation
A. Oranges is incorrect. Oranges are not a choking hazard as long as they are peeled and cut into small pieces for a toddler. The nurse should not include oranges in a list of choking hazards for toddlers.
B. Potatoes is incorrect. Potatoes themselves are not a choking hazard for toddlers, though whole or large pieces could pose a risk. The risk comes from how the food is prepared, not the food itself. If properly cooked and mashed or cut into small pieces, potatoes are safe.
C. Grapes is correct. Grapes are a common choking hazard for toddlers because they are small, round, and can easily block the airway if not properly cut into small pieces. The nurse should definitely include grapes in the pamphlet as a choking hazard.
D. Corn is incorrect. Corn kernels are not typically a choking hazard for toddlers unless they are served as whole kernels, which could pose a risk if not chewed properly. However, corn in the form of pureed corn or small pieces is safe for toddlers to eat.
Correct Answer is A
Explanation
A. Oral suction equipment is correct. During a seizure, there is a risk of aspiration due to the loss of airway control. Oral suction equipment should be readily available in the room to clear the airway if needed, especially if the client experiences a seizure with oral secretions.
B. Tongue depressor is incorrect. A tongue depressor should never be used during a seizure. Inserting a tongue depressor into the mouth can result in injury to both the client and the caregiver and should be avoided.
C. Tracheostomy tray is incorrect. While a tracheostomy tray might be necessary for clients with tracheostomies, it is not a standard requirement for clients on seizure precautions unless the client has specific respiratory concerns or requires a tracheostomy for airway management.
D. Wrist restraints is incorrect. Wrist restraints are not recommended during a seizure, as they can cause injury and impede movement. Instead, the goal is to provide a safe environment to prevent injury during a seizure.
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