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. Ankle is incorrect. The ankle is a hinge joint, which allows for movement in one plane (up and down), not the multidirectional movement characteristic of a ball and socket joint.
B. Shoulder is correct. The shoulder joint is a ball and socket joint. This type of joint allows for movement in multiple directions, including flexion, extension, abduction, adduction, rotation, and circumduction.
C. Knee is incorrect. The knee is a hinge joint, allowing for flexion and extension but not the wide range of motion that a ball and socket joint offers.
D. Metacarpophalangeal is incorrect. The metacarpophalangeal joints (knuckles) are condyloid joints, which allow for movement in two planes but not the full rotational movement of a ball and socket joint.
Correct Answer is C
Explanation
A. Doxazosin .5 mg PO at bedtime is incorrect. The dose should be written as "0.5 mg" to include the leading zero, following proper medication administration guidelines.
B. Lorazepam 0.5 mg PO PRN at bedtime is incorrect. "PRN" should include a specific indication (e.g., anxiety, insomnia. for when it is to be administered.
C. Heparin 5000 U subcutaneous every 8 hr is correct. The prescription is clear and includes the correct dose, route, and frequency of administration.
D. MgSO4 10 g PO daily is incorrect. Magnesium sulfate is typically administered intravenously, not orally, unless specified otherwise for specific conditions, and the dosage is quite high for oral administration.
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