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 ["B","C","D"]

Explanation

It is not appropriate for the nurse to threaten the client's child with reporting for maltreatment without further assessment and evidence.

Asking the client's child to provide details regarding the client's fractured arm will provide additional information about the client's injury and help the nurse assess the potential for abuse or neglect.

Discussing respite care options with the client's child may help alleviate any caregiver stress or burden, and ensure the client's continued care and safety.

Speaking to the client privately will help establish trust and rapport, and allow the client to disclose any

concerns or issues that they may not feel comfortable sharing in front of their child.

Providing legal advice regarding power of attorney is not within the scope of nursing practice and should be referred to a legal professional. Additionally, the client's capacity to make decisions and appoint a power of attorney should be assessed before providing such advice.

A. Wears an N95 mask when bathing a client who has Clostridium difficile B. Disposes of contaminated sheets in a linen bag C. Wears clean gloves when performing oral hygiene D. Empties the sharps container when it is full The correct answer is B

Correct Answer is B

Explanation

The nurse should identify that disposing of contaminated sheets in a linen bag demonstrates effective use of supplies.

Wearing an N95 mask when bathing a client with Clostridium difficile is important, but it is not related to effective use of supplies.

Wearing clean gloves when performing oral hygiene is standard practice for infection control and not specific to the use of supplies.

Empting the sharps container when it is full is also important, but it is not related to effective use of supplies.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","D"]

Explanation

A nurse is supervising an assistive personnel (AP) who is providing client care. The nurse should identify that which of the following actions by the AP demonstrates effective use of supplies?

Correct Answer is B

Explanation

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