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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Correct Answer is B
Explanation
A. "Provide homeschooling for your child" is not a necessary instruction. Children with cystic fibrosis can attend school, and with appropriate care, they can often manage their condition and participate in normal activities.
B. "Have your child wear a medical identification wristband" is correct. A medical identification wristband is important for children with cystic fibrosis as it can provide crucial information in an emergency, such as their diagnosis and specific care needs.
C. "Ensure that your child does not receive the influenza vaccine annually" is incorrect. Children with cystic fibrosis are at higher risk for respiratory complications and should receive the influenza vaccine annually to help prevent infection and reduce the risk of exacerbations.
D. "Do not include your child when making decisions about treatment" is incorrect. Involving children in their treatment decisions, as appropriate for their age and understanding, is important for fostering autonomy and ensuring they feel empowered in managing their condition.
Correct Answer is D
Explanation
A. The medication (erythromycin) is clearly identified in the prescription, so no clarification is needed regarding the drug name itself. B. The dosage (500 mg) is specified in the order, which is a standard dose for this medication, so it does not require clarification. C. The time or frequency is provided as “four times per day.” While specific facility times may need to be assigned, the frequency of administration is clearly established in the order. D. The route is entirely missing from the prescription. Erythromycin can be administered via several different routes, such as orally or intravenously, and the nurse cannot assume the intended method. This is a critical omission that must be clarified for safe transcription.
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