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 A
Explanation
A. Covering the wound with sterile, saline-soaked gauze is correct. Evisceration occurs when abdominal contents protrude through a surgical wound. To prevent drying and further tissue damage, the nurse should immediately cover the exposed organs with sterile gauze moistened with saline to maintain moisture and reduce infection risk.
B. Holding gentle, direct pressure on the protruding organ is incorrect. Applying pressure can cause further damage to the exposed tissue and increase the risk of complications. Instead, the focus should be on protecting the organs and minimizing contamination.
C. Placing the client’s knees in an extended position is incorrect. Keeping the knees straight can increase tension on the wound. Instead, the nurse should position the client with the knees slightly flexed to reduce strain on the abdominal incision.
D. Raising the head of the bed to a 45° angle is incorrect. A high Fowler’s position can increase pressure on the wound. The nurse should place the client in a low Fowler’s position (supine with knees slightly flexed. to reduce tension and prevent further protrusion.
Correct Answer is D
Explanation
A. "Once my health care proxy is in place, I relinquish my right to make my own decisions" is incorrect. A health care proxy only comes into effect when the individual becomes incapacitated and unable to make decisions. Until then, the client retains the right to make their own decisions.
B. "My health care proxy designee is not able to sign a consent form on my behalf" is incorrect. The health care proxy designee is authorized to make decisions about medical treatment, which includes signing consent forms on the client’s behalf if the client is unable to do so.
C. "If I have a health care proxy, then I do not need to have a living will" is incorrect. A living will and a health care proxy are separate documents. A living will specify a person’s wishes regarding medical treatments in case they are unable to communicate, while a health care proxy designates someone to make decisions on their behalf. Both can be used together.
D. "I do not need to name a relative as my designee in my health care proxy" is correct. The designee does not have to be a relative. The client can choose anyone they trust to make healthcare decisions on their behalf when they are unable to do so.
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