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 A

Explanation

A. Write the information at an 8th-grade reading level.: Health literacy is a key consideration when developing educational materials for the general public. Writing at an 8th-grade reading level ensures the content is accessible and understandable to a wide audience. This increases the likelihood that the target population will comprehend and retain the information.

B. Explain medical terminology using basic, one-syllable words.: While medical terms should be simplified, using only one-syllable words may result in oversimplification and miscommunication. Clear explanations should be provided in layman's terms, but not necessarily using only one-syllable words.

C. Use a 12-point font size.: A 12-point font size is a reasonable choice for readability, but 14-point or larger is often recommended for easier reading, especially for older adults or those with vision impairments.

D. Present information from complex to simple.: It is generally more effective to start with simple, basic concepts and build up to more complex information. Presenting information in a logical, structured manner—starting from the basics—will help the reader better understand the material.

A. "You should not palpate your child's abdomen prior to surgery." B. "Your child should have surgery in 7 to 10 days to remove the tumor." C. "You should give your child captopril 200 mg PO daily." D. "Your child will not require further treatment after removal of the tumor."

Correct Answer is A

Explanation

A. "You should not palpate your child's abdomen prior to surgery." is correct. Palpating the abdomen of a child with Wilms' tumor should be avoided, as this could cause the tumor to rupture and spread cancerous cells. The tumor is typically confined to one kidney and must be surgically removed.

B. "Your child should have surgery in 7 to 10 days to remove the tumor." is incorrect. Surgery to remove a Wilms' tumor typically occurs within 24 to 48 hours after diagnosis, not within 7 to 10 days.

C. "You should give your child captopril 200 mg PO daily." is incorrect. Captopril is not a standard medication used in the treatment of Wilms' tumor. Treatment often involves surgery, chemotherapy, and sometimes radiation therapy.

D. "Your child will not require further treatment after removal of the tumor." is incorrect. Post-surgical treatment, such as chemotherapy and/or radiation therapy, is often required, depending on the stage and extent of the tumor.

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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?

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