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. Measure the duration of the seizure. This is the correct action. Monitoring the duration of the seizure is important for assessing its severity and deciding when to intervene medically. A seizure lasting longer than 5 minutes requires immediate intervention.

B. Lower the side rails of the bed when the seizure begins. This is not recommended. The side rails should be raised to protect the client from injury. Lowering them could increase the risk of falling out of bed.

C. Insert an oral airway into the client's mouth. This is incorrect. Inserting an airway into the mouth during a seizure can be dangerous and may result in injury to the client or the nurse. The client’s airway should be kept clear, but inserting an object into the mouth is not recommended.

D. Restrain the client's arms and legs to prevent injury. This is incorrect. Restraining the client during a seizure can cause injury to both the client and the nurse. It is better to allow the seizure to proceed naturally while ensuring the client is protected from injury (e.g., by placing a soft pillow under their head or cushioning hard surfaces around them).

A. "Take an extra dose of insulin lispro prior to aerobic exercise." B. "Draw up the insulin lispro and insulin glargine in separate syringes." C. "Expect insulin glargine to be cloudy." D. "Anticipate that the insulin glargine will peak in 3 hours."

Correct Answer is B

Explanation

A. "Take an extra dose of insulin lispro prior to aerobic exercise." This is incorrect. Exercise can increase insulin sensitivity, meaning the client may need to reduce the dose of short-acting insulin (such as insulin lispro) before exercise to avoid hypoglycemia. The nurse should not recommend taking an "extra" dose of insulin prior to exercise.

B. "Draw up the insulin lispro and insulin glargine in separate syringes." This is correct. Insulin lispro (a rapid-acting insulin) and insulin glargine (a long-acting insulin) should never be mixed in the same syringe. Insulin glargine is acidic, and mixing it with other insulins can alter its action and effectiveness.

C. "Expect insulin glargine to be cloudy." This is incorrect. Insulin glargine should be clear and colorless. If insulin glargine appears cloudy, it may indicate that the insulin is expired or has been improperly stored.

D. "Anticipate that the insulin glargine will peak in 3 hours." This is incorrect. Insulin glargine has no pronounced peak. It provides a steady release of insulin over 24 hours and is designed to be taken once daily.

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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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