A client is concerned about their 3-year-old child's respiratory rate. What action should the nurse take to ensure an accurate measurement?
Count respirations immediately after the child eats.
Observe chest movement for one full minute.
Use a stopwatch to time respirations.
Ask the child to take deep breaths during the assessment.
The Correct Answer is B
A. Incorrect. Counting respirations immediately after eating may not provide an accurate measurement, as activity or digestion can influence respiratory rate.
B. Correct. Observing chest movement for a full minute allows for an accurate assessment of respiratory rate in children.
C. Incorrect. While using a stopwatch may be helpful, it is not necessary to ensure an accurate respiratory rate measurement in this context.
D. Incorrect. Asking the child to take deep breaths may not reflect their natural respiratory rate and could lead to an inaccurate assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Placing the hand on the infant's abdomen allows the nurse to feel the rise and fall with each breath, providing an accurate count of respiratory rate.
B. Incorrect. Counting respirations while the infant is sleeping may be challenging and may not provide an accurate assessment.
C. Incorrect. While visually observing chest movement can be helpful, this method may not be as accurate as feeling the actual movement with the hand.
D. Incorrect. Using a stethoscope to listen for breath sounds is not the recommended method for measuring respiratory rate in infants.
Correct Answer is B
Explanation
A. Incorrect. Pulling the child's earlobe down and back is a technique used for straightening the ear canal in older children and adults, not for using a tympanic thermometer.
B. Correct. When using a tympanic thermometer, it's important to gently insert the probe into the ear canal and ensure a proper seal. This helps to obtain an accurate temperature reading.
C. Incorrect. Holding the thermometer in place for 1-2 minutes is not the correct technique for tympanic temperature measurement. It may lead to an inaccurate reading.
D. Incorrect. Using an oral thermometer for a 2-year-old child is not the recommended method, as it may not provide an accurate temperature reading.
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