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. Thrombocytopenia: Neither atenolol nor nitroglycerin is commonly associated with thrombocytopenia. This is not the primary concern when these two medications are used together.

B. Dry cough: A dry cough is a known side effect of ACE inhibitors (e.g., enalapril), but it is not commonly associated with atenolol or nitroglycerin.

C. Hypotension: Both atenolol (a beta-blocker) and nitroglycerin (a vasodilator) can lower blood pressure. When taken together, there is an increased risk of hypotension, especially when standing up quickly. The nurse should monitor the client for symptoms of low blood pressure such as dizziness, fainting, or lightheadedness.

D. Hyperglycemia: Atenolol may mask signs of hypoglycemia in clients with diabetes, but it does not directly cause hyperglycemia. Nitroglycerin is not typically associated with hyperglycemia either. Therefore, hyperglycemia is not a concern in this scenario.

A. Elevated blood pressure B. Bounding pulse C. Fruity breath odor D. Clammy skin

Correct Answer is C

Explanation

A. Elevated blood pressure: Diabetic ketoacidosis (DKA. typically does not cause elevated blood pressure. In fact, due to dehydration from increased urination, clients often present with hypotension or normal blood pressure, rather than hypertension.

B. Bounding pulse: A bounding pulse is not commonly associated with DKA. It may be seen with conditions such as fever or sepsis, but DKA is more likely to cause a weak or thready pulse due to fluid volume deficit and dehydration.

C. Fruity breath odor: A fruity or acetone-like breath odor is a hallmark sign of diabetic ketoacidosis. This is caused by the presence of ketones in the blood, which are produced as the body breaks down fat for energy when glucose is unavailable.

D. Clammy skin: Clammy skin is more likely to be associated with hypoglycemia, not DKA. In DKA, the skin is typically dry due to dehydration, and the client may appear flushed, not clammy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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