A nurse is instructing a group of nursing students in measuring a client’s respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply)

Place the client in semi-Fowler’s position

Have the client rest an arm across the abdomen

Observe one full respiratory cycle before counting the rate

count the rate for 30 sec if it is irregular

Count and report any sighs the client demonstrates

Answer and Explanation

Correct Answer : C,E

A. Place the client in semi-Fowler’s position:

While the semi-Fowler's position can be helpful in assessing respiratory function, it is not specifically required for measuring the respiratory rate. The key is to ensure the client is comfortable and able to breathe easily.

B. Have the client rest an arm across the abdomen:

Placing the arm across the abdomen is not a standard practice for measuring respiratory rate. The key is to allow the client to breathe naturally, and this position is not necessary for accurate measurement.

C. Observe one full respiratory cycle before counting the rate:

This ensures that the count is accurate and reflective of the client's typical breathing pattern.

D. Count the rate for 30 seconds if it is irregular:

When measuring the respiratory rate, it is generally recommended to count for a full minute to obtain an accurate representation of the client's breathing pattern. Counting for 30 seconds may underestimate or overestimate the rate, especially if the irregularity is not consistent.

E. Count and report any sighs the client demonstrates:

Sighs can be indicative of emotional or physiological stress, and noting them is important for a comprehensive respiratory assessment.

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Correct Answer is ["45"]

Explanation

To calculate the amount of potassium chloride (K-Dur) solution to administer, we need to use the following formula:

mL to administer = ordered dose (mEq) / available dose (mEq/mL) x mL

Plugging in the values from the question, we get:

mL to administer = 60 mEq / (20 mEq / 15 mL) x 15 mL

Simplifying the equation, we get:

mL to administer = 60 mEq x 15 mL / 20 mEq

mL to administer = 45 mL

Therefore, the nurse should administer 45 mL of potassium chloride (K-Dur) solution to the patient.

A. Documentation is a communication tool for the interprofessional health care team B. Documentation allows providers to monitor the nurse’s activities C. Documentation provides information to the client about financial charges. D. Documentation provides information for a client audit

Correct Answer is A

Explanation

A. Documentation is a communication tool for the interprofessional health care team

The purpose of documentation in the electronic health record (EHR) includes serving as a communication tool among members of the interprofessional healthcare team. Accurate and timely documentation allows healthcare providers to share information about the client's care, treatment, and outcomes.

B. Documentation allows providers to monitor the nurse’s activities:

While documentation provides a record of the nurse's activities, the primary purpose is to communicate information about patient care rather than serving as a tool for monitoring the nurse's activities.

C. Documentation provides information to the client about financial charges:

The primary purpose of documentation is to record and communicate information about the client's health status, care, and outcomes. Financial information is typically managed separately from clinical documentation.

D. Documentation provides information for a client audit:

While documentation can be used in audits for quality assurance, the primary purpose is to record and communicate information about patient care. The use of documentation for audits is a secondary function related to quality improvement and regulatory compliance.

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A nurse is instructing a group of nursing students in measuring a client’s respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Ordered: Potassium chloride (K-Dur) 60 mEq Available: Potassium chloride (K-Dur) 20 mEq/15 mL Administer: _____mL

Correct Answer is ["45"]

Explanation

A nurse is orienting a newly licensed nurse about documentation of a client’s information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?

Correct Answer is A

Explanation

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