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
Physical assessment findings are important to include in a referral for a physical therapist because they provide information about the client's current physical condition, including range of motion, strength, and any areas of pain or discomfort. This information is essential for the physical therapist to develop an appropriate treatment plan for the client. Family medical history and medical health insurance claims may be important for overall client care but are not directly relevant to a referral for a physical therapist.
Medications taken prior to admission may be relevant if they affect the client's physical abilities or pain level, but again, physical assessment findings are more directly related to the referral for a physical therapist.
Correct Answer is D
Explanation
A.Using hydrogen peroxide for wound cleaning is not recommended as it can cause tissue damage and delay healing.
B.Burn dressings should typically be changed more frequently, often at least once per day, depending on the type and severity of the burn and the type of dressing used.Delaying dressing changes could increase the risk of infection.
C.In wound care, the nurse should cleanse the least contaminated wounds first to prevent spreading microorganisms from more contaminated areas to cleaner areas. This reduces the risk of cross-contamination and infection. For burns, starting with the cleanest areas ensures a safer wound management process.
D.Applying dressings with sterile gloves is essential to maintain a sterile environment and reduce the risk of infection, especially in clients with burns who are at high risk for infection due to compromised skin integrity.
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