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. Limiting the number of choices for the client is correct. Clients with Alzheimer's disease can become overwhelmed by too many options. Offering simple choices, such as "Would you like tea or juice?" instead of an open-ended question, helps reduce confusion and frustration.

B. Using written signs to assist with locating the bathroom is incorrect. While cues can be helpful, clients with Alzheimer's disease often experience difficulty processing written information as the disease progresses. Using pictures or symbols instead of words is more effective.

C. Providing a stimulating environment for the client is incorrect. An overly stimulating environment can increase agitation and confusion. A calm, structured setting with minimal distractions is better for clients with Alzheimer's disease.

D. Using confrontation to manage the client’s behavior is incorrect. Confronting or arguing with a client who has Alzheimer's disease can lead to increased agitation and distress. Instead, caregivers should use redirection and reassurance to manage behaviors effectively.

A. The telephone numbers of the clients B. The room numbers of the clients C. The diagnoses of the clients D. The names of the clients' nearest relatives

Correct Answer is A

Explanation

A. Using the telephone numbers of the clients is correct. According to The Joint Commission's National Patient Safety Goals, at least two unique identifiers, such as date of birth and telephone number, should be used to verify client identity before administering medications to prevent errors.

B. Using the room numbers of the clients is incorrect. Room numbers can change, and relying on them increases the risk of medication errors if a client is moved or misidentified.

C. Using the diagnoses of the clients is incorrect. A diagnosis is not a unique identifier, as multiple clients in a unit may have the same or similar conditions, leading to potential confusion.

D. Using the names of the clients' nearest relatives is incorrect. Family members’ names do not provide a direct, unique way to verify the client’s identity, making them unreliable for medication administration.

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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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