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 D

Explanation

A. Referring to a physical therapist is incorrect. Physical therapists focus on improving mobility, strength, and balance, but they do not typically assist with transportation needs or alternative arrangements for follow-up appointments.

B. Referring to a primary care provider is incorrect. While the primary care provider oversees medical care and follow-ups, they do not arrange transportation services or address logistical concerns regarding appointments.

C. Referring to an occupational therapist is incorrect. Occupational therapists help clients regain skills for daily living, including adaptive techniques for driving, but they do not arrange transportation.

D. Referring to a social worker is correct. Social workers help clients identify resources, such as transportation services, to ensure they can attend medical appointments and access necessary care.

A. Replace the ear molds once per year. B. Clean the hearing aid with a soft cloth. C. Disinfect the hearing aid with isopropyl alcohol. D. Change the battery once per month.

Correct Answer is B

Explanation

A. "Replace the ear molds once per year" is incorrect. Ear molds should be checked regularly for wear and tear, but they should be replaced as needed rather than on a fixed schedule like once a year.

B. "Clean the hearing aid with a soft cloth" is correct. Cleaning the hearing aid with a soft cloth helps to maintain the device, removing dirt and debris without damaging the electronics. It is important to avoid using harsh chemicals or abrasive materials that could harm the hearing aid.

C. "Disinfect the hearing aid with isopropyl alcohol" is incorrect. Isopropyl alcohol is too harsh for cleaning hearing aids and can damage the components. The hearing aid should only be cleaned with appropriate methods, such as a dry cloth or cleaning brush.

D. "Change the battery once per month" is incorrect. The battery should be checked more frequently, as it typically needs to be replaced more often (e.g., every 7-10 days), depending on usage. Changing it once a month may not ensure optimal performance.

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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?

Nursing Test Bank

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