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 C
Explanation
The rotavirus vaccine is administered orally, usually in the form of drops. It is given to infants to protect against rotavirus, which is a common cause of severe diarrhea and dehydration in young children. By stating that the baby will receive the rotavirus immunization orally, the guardian demonstrates an understanding of this specific vaccination.
There is no need to restrict feeding for a specific duration before immunization unless otherwise specified by the healthcare provider. In general, it is important to ensure that the infant is well-fed and hydrated.
While mild side effects such as low-grade fever, fussiness, or local soreness at the injection site may occur after immunizations, having a high fever for 24 hours is not a typical or expected reaction. If a high fever or any concerning symptoms develop after immunization, it is important to contact the healthcare provider.
The number of doses and the schedule for meningococcal immunization can vary depending on the specific vaccine used and the recommendations of the healthcare provider or local guidelines.
Correct Answer is B
Explanation
This is done by aspirating a small amount of stomach contents and testing the pH using pH paper or a pH indicator strip. The pH of stomach contents is typically acidic (pH less than 5), indicating proper placement in the stomach.
Injecting air and listening for bubbling is not a reliable method to verify tube placement, as it can lead to complications such as pneumothorax.
Measuring gastric residual is done to assess the amount of gastric contents remaining in the stomach, but it does not confirm tube placement.
Adding food coloring to the formula is not a standard practice and does not provide reliable confirmation of tube placement.
X-ray is the gold standard method to confirm tube placement but is not typically done before every intermittent feeding unless there are concerns about tube placement
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