A nurse is assessing a client's respiratory rate and finds it to be irregular, with periods of deep breaths alternating with shallow breaths. What action should the nurse take?
Document the finding as a normal variation.
Reassess the respiratory rate after 30 minutes.
Initiate oxygen therapy.
Notify the healthcare provider of the irregular breathing pattern.
The Correct Answer is D
Answer: d. Notify the healthcare provider of the irregular breathing pattern.
Explanation: An irregular breathing pattern with alternating periods of deep and shallow breaths may indicate a respiratory disorder or impairment. The nurse should notify the healthcare provider for further evaluation and intervention.
a. Documenting the irregular breathing pattern as a normal variation would be inappropriate since it may indicate an underlying respiratory issue.
b. Reassessing the respiratory rate after 30 minutes may delay appropriate intervention if there is an underlying respiratory problem.
c. Initiating oxygen therapy is not the first-line intervention based solely on an irregular breathing pattern but requires further assessment and evaluation.
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Related Questions
Correct Answer is C
Explanation
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.
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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