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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 B

Explanation

The PCA (patient-controlled analgesia) pump is programmed to deliver a dose of 0.5 mg of morphine every 15 minutes as needed. This setup means that only 1 dose can be administered every 15 minutes, regardless of how many times the patient presses the button.

Since 60 minutes have passed, the maximum number of doses the patient could receive is calculated as follows:

60 minutes/ 15 minutes per dose= 4 doses

Even though the patient pressed the button 10 times, the pump will only deliver a dose every 15 minutes, resulting in 4 doses.

A. Use only written communication whenever possible to minimize the client's frustration. B. Minimize background noises such as the television and ensure that lighting is adequate to see the nurse's face. C. Use vocabulary and concepts that are as simple as possible. D. Repeat each direction or question multiple times, even if the client states he heard and understands the directions.

Correct Answer is B

Explanation

A. Use only written communication whenever possible to minimize the client's frustration.Written communication can be helpful in some situations, but it should not be the primary mode of communication for clients with moderate hearing loss unless necessary.

B. Minimize background noises such as the television and ensure that lighting is adequate to see the nurse's face.Reducing background noise and ensuring proper lighting are critical strategies for effective communication with individuals with hearing loss. These steps make it easier for the resident to hear and understand, and they also allow the resident to use visual cues, such as lip-reading, to enhance communication.

C. Use vocabulary and concepts that are as simple as possible.
While simplifying vocabulary may help some individuals, it is not necessary or beneficial for all residents with hearing loss. This could come across as condescending unless it aligns with the client’s cognitive ability.

D. Repeat each direction or question multiple times, even if the client states he heard and understands the directions: Repeating unnecessarily can be frustrating and counterproductive for the client. It is more effective to ensure the initial communication is clear and check for understanding without excessive repetition unless the resident indicates they need clarification.

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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.

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Naxlex Comprehensive Predictor Exams

A patient is on a PCA pump following an abdominal surgery. The order states the client can have 0.5mg morphine every 15 minutes as needed. The client pushed the button 10 times in the past 60 minutes. How many doses did the client receive?

Correct Answer is B

Explanation

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Correct Answer is B

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.