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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.7"]
Explanation
To calculate the amount of hydroxyzine (Vistaril) to administer, use the formula:
D (desired dose) / H (have dose) x Q (quantity) = X (amount to give)
In this case, D = 35 mg, H = 50 mg/mL, and Q = 1 mL. Plug in the values and solve for X:
35 mg / 50 mg/mL x 1 mL = 0.7 mL
Therefore, the amount of hydroxyzine (Vistaril) to administer is 0.7 mL.
Correct Answer is B
Explanation
A. Redo the initial assessment and document current findings:
This option suggests repeating the entire initial assessment. While reassessment is important, redoing the entire initial assessment may not be necessary. Instead, a focused assessment on the specific area of concern (skin integrity) is more appropriate.
B. Perform and document a focused assessment of skin integrity:
This is the recommended choice. If unexpected findings are observed during care, such as reddened areas over bony prominences, it is important to conduct a focused assessment on the skin to identify any issues and document the findings accurately.
C. Correct the initial assessment form:
Simply correcting the initial assessment form may not address the immediate need for assessing and addressing the reddened areas. It is more crucial to perform a focused assessment on the skin.
D. Conduct and document an emergency assessment:
Reddened areas over bony prominences may not necessarily indicate an emergency. However, addressing the issue promptly is important. A focused assessment would be more appropriate than conducting a full emergency assessment.
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