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.
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Related Questions
Correct Answer is ["B","C"]
Explanation
Turn cellular phones to silent mode: In an active shooter situation, it is crucial to maintain silence to avoid drawing attention to your location. Switching cellular phones to silent mode helps ensure that ringtones or notifications do not alert the shooter to your presence.
Wave hands to attract the attention of law enforcement: When law enforcement or emergency personnel arrive at the scene, it is essential to signal to them that you are not a threat and that you require assistance. This can be done by putting hands up, keeping them visible, and following any instructions provided by law enforcement.
Move wounded clients to a safe area before finding shelter: It is important to prioritize the safety of individuals involved in an active shooter situation. However, moving wounded clients should be done only if it can be done quickly and without putting oneself or others at risk. The primary goal is to seek safety and follow established protocols, such as "run, hide, fight" principles, rather than focusing on moving injured individuals during an ongoing threat.
Attempt to bargain with the shooter: Bargaining or negotiating with an active shooter is strongly discouraged. It is important to remember that the primary goal in an active shooter situation is to ensure personal safety and the safety of others. Engaging with the shooter may escalate the situation or put oneself and others at greater risk.
The in-service should focus on providing staff members with practical guidance on how to respond to an active shooter situation, emphasizing the importance of following established protocols, staying calm, and seeking safety. Additionally, the in-service should include training on recognizing and reporting suspicious behavior, as prevention and early intervention can play a crucial role in mitigating such incidents.
Correct Answer is B
Explanation
Furosemide is a diuretic medication that helps remove excess fluid from the body by increasing urine production and output. In a client with heart failure, one of the indicators that the medication is effective is an increase in urinary output. This can help reduce fluid buildup in the body, which can improve symptoms of heart failure.
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