A nurse is assessing a client's respiratory rate and finds it to be 30 breaths per minute. What action should the nurse take?
Document the respiratory rate as normal.
Initiate oxygen therapy.
Assess the client for signs of respiratory distress.
Administer a sedative medication.
The Correct Answer is C
Answer: c. Assess the client for signs of respiratory distress.
Explanation: A respiratory rate of 30 breaths per minute is above the normal range (12-20 breaths per minute) and may indicate tachypnea or increased work of breathing. The nurse should assess the client for signs of respiratory distress and investigate the underlying cause.
a. Documenting the respiratory rate as normal would be inaccurate since it is above the normal range.
b. Initiating oxygen therapy is not the first-line intervention based solely on an increased respiratory rate but requires a comprehensive assessment of the client's respiratory status.
d. Administering a sedative medication is not appropriate solely based on an increased respiratory rate without further assessment.
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Related Questions
Correct Answer is A
Explanation
Answer: a. On the client's finger
Explanation: The pulse oximeter sensor is typically placed on the client's finger to accurately measure the respiratory rate. The sensor detects changes in blood volume and oxygen saturation, which correlate with respiratory cycles.
b. Placing the pulse oximeter sensor on the client's forehead is not the standard practice for measuring the respiratory rate.
c. Placing the pulse oximeter sensor on the client's chest is not necessary for measuring the respiratory rate as it primarily assesses oxygen saturation.
d. Placing the pulse oximeter sensor on the client's earlobe is not the standard practice for measuring the respiratory rate.
Correct Answer is A
Explanation
Answer: a. Visual observation of chest movements
Explanation: The nurse should visually observe the client's chest movements to accurately measure the respiratory rate. This involves counting the number of complete inhalations and exhalations within a minute.
b. Auscultation of breath sounds is used to assess the quality of breath sounds but does not provide an accurate measurement of the respiratory rate.
c. Palpation of the client's abdomen is not the primary method for measuring the respiratory rate.
d. Using a respiratory rate monitor may provide an objective measurement, but visual observation is the most common and readily available technique.
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