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 D
Explanation
This statement shows that the client understands the threshold for high blood pressure readings. A blood pressure reading of 140/90 mmHg or higher is considered elevated or hypertensive.
It is important for the client to be aware of this value and to seek medical attention or follow the prescribed management plan if their blood pressure exceeds this threshold.
The hand should be supported at the level of the heart or positioned comfortably during blood pressure measurement, but it does not need to be specifically 6 inches below the heart.
Consistency in the timing of blood pressure measurements is important for accurate monitoring. It is generally recommended to measure blood pressure at the same time each day to account for variations that can occur throughout the day.
The blood pressure cuff should be snug but not too tight around the upper arm. It should fit comfortably and securely to ensure accurate readings.
Correct Answer is C
Explanation
Instruct the client to close their mouth tightly around the mouthpiece of the inhaler. This ensures that the medication is delivered directly into the lungs and minimizes the amount of medication escaping into the surrounding environment.
The correct technique for using a metered-dose inhaler does not involve tilting the head forward.
Instead, the client should keep their head in a neutral position while using the inhaler. After inhaling the medication from the inhaler, it is recommended to hold the breath for about 10 seconds before exhaling. This allows the medication to be fully deposited in the lungs and absorbed effectively.
The proper technique for using an albuterol metered-dose inhaler involves taking a slow and deep breath. The client should depress the canister once at the beginning of inhalation and continue to inhale slowly and deeply to ensure adequate medication delivery.
It is important for the nurse to demonstrate and observe the client's technique while using the inhaler to ensure proper administration.
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