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A nurse is instructing a group of nursing students in taking vital signs and assessing a client's respiratory status.
Which of the following guidelines should the nurse include? Select all that apply.

Act as if you are still taking the radial pulse while assessing respiratory rate so the client does not know you are counting.

If the respiratory rate is regular, count for 30 seconds and multiply by 2.

Observe the depth and rhythm of the respirations.

Count a full respiratory cycle (inhalation and exhalation)

Answer and Explanation

Correct Answer : B,C,D

The correct answer is choices B, C, and D.

When assessing respiratory rate, it is important to count for a full respiratory cycle, which includes both inhalation and exhalation. If the respiratory rate is regular, the nurse can count for 30 seconds and multiply by 2 to obtain the total number of breaths per minute. The nurse should also observe the depth and rhythm of the respirations, noting any abnormalities or changes. It is not recommended to pretend to take the radial pulse while assessing respiratory rate, as this can lead to inaccurate readings and is not a professional approach to care

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Correct Answer is A

Explanation

The correct answer is choice A, moisture in air passages. Crackles, also known as rales, are abnormal lung sounds that can indicate a buildup of fluid in the lungs. The moisture in the air passages causes the sound of air moving through fluid or mucus, leading to a crackling sound. Crackles can be heard in conditions such as pneumonia, heart failure, and pulmonary fibrosis.

Correct Answer is ["333"]

Explanation

To calculate the infusion rate, we need to divide the total volume to be infused by the total time of infusion and then multiply by 60 to convert to mL/h:

1000 mL ÷ 3 hours = 333.33 mL/h

Rounding to the nearest whole number, the IV pump should be programmed for 333 mL/h.

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A nurse is instructing a group of nursing students in taking vital signs and assessing a client's respiratory status. Which of the following guidelines should the nurse include? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing breath sounds, a nurse hears crackles. What causes these lung sounds?

Correct Answer is A

Explanation

A patient has an order for Normal Saline 1000 mL to infuse over 3 hours. The medication will be infused with an IV pump. How many mL/h should the IV pump be programmed for?

Correct Answer is ["333"]

Explanation

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A nurse is instructing a group of nursing students in taking vital signs and assessing a client's respiratory status.
Which of the following guidelines should the nurse include? Select all that apply.