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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Related Questions
Correct Answer is D
Explanation
A. "My child still wets the bed at least two times per week." While this is a concern, bedwetting can be a normal developmental behavior for children at this age and does not necessarily indicate a problem unless it persists beyond the typical age range.
B. "I have a difficult time getting my child to eat green vegetables." This is a common concern for parents of young children and typically does not warrant immediate attention, although it may require guidance on healthy eating habits.
C. "My child continually asks me the same questions." Repetition of questions is a normal part of cognitive development in young children and does not indicate an issue by itself.
D. "I have noticed that my child is withdrawn since we switched day care providers." This is the priority concern. Withdrawal or behavioral changes, particularly after a significant event like a change in day care, can indicate stress, anxiety, or possible emotional issues, and the nurse should address this promptly to ensure the child's well-being.
Correct Answer is ["A","B","C","E"]
Explanation
A. Keep track of how long it takes to complete certain tasks is correct. Tracking the time it takes to complete tasks can help the nurse identify areas for improvement and prioritize tasks accordingly.
B. Delegate collection of vital signs to the assistive personnel on the team is correct. Delegating tasks such as vital sign monitoring to assistive personnel allows the nurse to focus on higher-level clinical duties and improves time management.
C. Make a priority to-do list at the beginning of the shift is correct. Creating a to-do list helps the nurse organize tasks based on urgency, improving overall time management and ensuring critical tasks are addressed.
D. Plan a time at the end of the shift to document nursing interventions is incorrect. Documentation should be done throughout the shift as interventions are performed, not solely at the end. Delaying documentation can lead to errors and missed information.
E. Complete activities with one client before moving to another client is correct. Focusing on one client at a time helps ensure each task is completed thoroughly and reduces the risk of neglecting important care steps.
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