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.

Answer and Explanation

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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Correct Answer is C

Explanation

a.While reporting the incident is important, the priority is to stop the confidentiality breach immediately to protect the client's privacy.

b.Participating in training is important for long-term education, but it does not address the immediate issue of the confidentiality breach.

c. Tell the staff members to stop their discussion: This action stops the breach immediately and protects the client's confidential information, which is the first and most crucial step.

d.Speak to the staff members in private about client confidentiality: While this is a good follow-up action to educate and prevent future breaches, the immediate need is to stop the ongoing discussion

A. Apply pressure to the lacrimal punctum after administering the drops. B. Position the child side-lying on the bed before administering the drops. C. Wipe from the outer to the inner canthus after administering the drops. D. Flush the eye with normal saline solution before administering the drops.

Correct Answer is A

Explanation

When administering eye drops to a child, the nurse should apply gentle pressure to the lacrimal punctum (the small opening in the inner corner of the eye) after administering the drops. This can help prevent the medication from draining into the tear duct and being absorbed into the bloodstream, which can reduce systemic side eﬀects.

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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

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