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. Ringing in the ears (tinnitus) is incorrect. Tinnitus is not a common adverse effect of propranolol. This symptom is more commonly associated with ototoxic medications, such as certain antibiotics or diuretics.

B. Bradycardia is correct. Propranolol is a beta-blocker that reduces heart rate and blood pressure by blocking beta-adrenergic receptors. One of its primary adverse effects is bradycardia (slow heart rate., which can lead to dizziness, fatigue, or hypotension.

C. Hypertension is incorrect. Propranolol is used to treat hypertension, not cause it. By reducing cardiac output and suppressing sympathetic nervous system activity, propranolol generally lowers blood pressure.

D. Headache is incorrect. While some clients might experience headaches due to changes in blood pressure, headache is not a primary adverse effect of propranolol.

A. Chadwick's sign B. Hegar's sign C. Chloasma D. Ballottement

Correct Answer is A

Explanation

A. Chadwick's sign is correct. Chadwick's sign refers to a purplish or bluish discoloration of the vagina and vulva that occurs early in pregnancy due to increased blood flow to the pelvic area. This is typically seen around the 8th week of gestation.

B. Hegar's sign is incorrect. Hegar's sign refers to the softening of the lower uterine segment, which is a physical change that can be felt during a pelvic examination. It is a sign of pregnancy but does not involve discoloration of the vaginal area.

C. Chloasma is incorrect. Chloasma, also called the "mask of pregnancy," refers to hyperpigmentation on the face, typically over the cheeks and forehead, not the vagina or vulva.

D. Ballottement is incorrect. Ballottement refers to a physical finding during a pelvic exam in which the examiner can feel the fetus floating in the amniotic fluid, typically observed after 16 weeks of pregnancy. It is unrelated to changes in vaginal or vulvar color.

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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

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is contributing to the plan of care for a client who has a new prescription for propranolol. The nurse should plan to monitor the client for which of the following adverse effects of the medication?

Correct Answer is B

Explanation

A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation. The nurse notes that the client's vagina and vulva are a purplish color. The nurse should document this finding as which of the following?

Correct Answer is A

Explanation

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