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?
Place the client in a supine position.
Observe the movements of the client's chest wall.
Inform the client when beginning to observe his respirations.
Count the client's respirations for 15 seconds.
The Correct Answer is B
To accurately assess the client's respirations, the nurse should observe the movements of the client's chest wall. This can be done by visually inspecting the rise and fall of the chest or by placing a hand on the client's chest to feel the movements. This allows the nurse to assess the depth, rhythm, and effort of the client's breathing. I
It is important to observe the client's respirations without informing them, as this may cause the client to alter their breathing pattern consciously.
Counting the client's respirations for a full minute (rather than 15 seconds) provides a more accurate measurement.
Placing the client in a supine position may not be necessary for assessing respirations, as it is primarily focused on observing the chest movements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Stomatitis is an inflammation of the oral mucosa, which can cause pain, discomfort, and difficulty eating. To manage stomatitis, clients should consume soft, bland foods that are easy to chew and swallow, such as cooked vegetables, mashed potatoes, and oatmeal.
Acidic, spicy, or crunchy foods should be avoided. Using lemon glycerin swabs can irritate the oral mucosa, so they should not be used.
Mouthwashes containing alcohol can cause further irritation, so they should also be avoided. Eating foods high in vitamin B12 can be helpful for preventing stomatitis, but it is not an appropriate intervention for managing an existing case of stomatitis.
Correct Answer is A
Explanation
The normal range for potassium levels is generally between 3.5 to 5.0 mEq/L. A potassium level of 3.5 mEq/L falls within the lower end of the normal range, suggesting that the client's potassium levels are relatively stable. This finding alone does not indicate the overall effectiveness of the behavioral plan.
The normal range for sodium levels is typically between 135 to 145 mEq/L. A sodium level of 130 mEq/L falls below the normal range and indicates hyponatremia (low sodium levels). Hyponatremia can be a cause for concern, and it suggests that the behavioral management plan may need further attention or adjustments.
The normal range for hemoglobin (Hgb) levels varies depending on factors such as age and gender. However, in general, a Hgb level of 10 g/dL falls below the normal range and indicates anemia. Anemia is a common complication in individuals with anorexia nervosa and can result from inadequate nutrient intake. This finding suggests that the behavioral plan may need further evaluation and adjustment to address the client's nutritional needs.
Body Mass Index (BMI) is a measure that relates weight and height. A BMI of 14.5 indicates severe underweight and is well below the normal range. This finding suggests that the client's nutritional status is still significantly compromised, and the behavioral management plan may require further attention to support weight restoration and overall recovery.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today