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 D
Explanation
A. Leaving noninvasive equipment on the client’s body is not appropriate during postmortem care. Tubing and devices should be removed unless an autopsy is required.
B. Dentures should generally be left in place to maintain the natural shape of the face and promote a more normal appearance for family viewing.
C. Turning the lights up is unnecessary and may create a harsh environment. A calm, respectful setting with normal or dim lighting is preferred during postmortem care.
D. Closing the client’s eyes before the family views the body helps provide a peaceful and dignified appearance and is an important part of postmortem care.
Correct Answer is A
Explanation
A. The client develops chest pain each time he talks about his partner is an indication of complicated grief. The client’s experience of intense, physical symptoms like chest pain when discussing their partner suggests that the grief process may not be progressing and could indicate unresolved or complicated grief.
B. The client keeps a framed picture of his partner on the wall is a normal expression of grief. Keeping a picture of a lost loved one is common and doesn’t necessarily indicate complicated grief. It can be part of the natural grieving process.
C. The client reports he has no interest in dating is not necessarily a sign of complicated grief. It's common for people grieving to not have an interest in dating or forming new romantic relationships immediately after the loss, but it does not suggest a problem unless the client expresses prolonged avoidance of all social interaction.
D. The client attends a grief support group twice each month is a positive coping mechanism. Attending support groups shows the client is actively engaging with the grieving process and seeking support, which is part of healthy adjustment after a loss.
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