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 B

Explanation

A. "I can take antacids at the same time as this medication.": This is incorrect. Pantoprazole is a proton pump inhibitor (PPI), and taking antacids at the same time can interfere with the medication's effectiveness. It is generally recommended to space out antacids and PPIs by at least 1 hour.

B. "I have to take this medication on an empty stomach.": This is correct. Pantoprazole should be taken on an empty stomach, typically 30 minutes before breakfast, to optimize absorption and effectiveness.

C. "I should expect to have diarrhea while taking this medication.": Diarrhea is not a common side effect of pantoprazole. While side effects such as headache, nausea, and abdominal pain are more common, diarrhea is not typically expected.

D. "I will need to remain upright for 1 hour after taking the medication.": This is incorrect. While it is generally advised to remain upright for a period after taking medications like bisphosphonates, it is not required for pantoprazole. The main instruction for pantoprazole is to take it on an empty stomach before eating.

A. "I can prevent nausea if I take the medication on an empty stomach." B. "I can prevent constipation if I drink more milk while taking this medication." C. "I will report black stools to my doctor." D. "I will mix the medication with a full glass of water."

Correct Answer is C

Explanation

A. "I can prevent nausea if I take the medication on an empty stomach." This is incorrect. Taking ferrous sulfate on an empty stomach may increase the risk of gastrointestinal upset, including nausea. It is typically recommended to take it with food to reduce these side effects, although it may be less effective if taken with certain foods or beverages.

B. "I can prevent constipation if I drink more milk while taking this medication." This is incorrect. Milk can actually worsen constipation, and clients taking ferrous sulfate should focus on increasing fiber intake and drinking plenty of fluids to prevent constipation.

C. "I will report black stools to my doctor." This is correct. Black stools are a common side effect of iron supplementation, but it is essential for the client to report it to the doctor if they are concerned, as it could also indicate gastrointestinal bleeding in some cases.

D. "I will mix the medication with a full glass of water." While taking the medication with a full glass of water is appropriate, it is not the most significant instruction regarding the use of the medication. Therefore, while the answer isn't wrong, it doesn't indicate the client's understanding of the most important aspects, such as monitoring for side effects like black stools.

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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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