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)
Count a full respiratory cycle (inhalation and exhalation)
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A pureed diet is a type of texture-modified diet where food is blended to a smooth consistency to make it easier to swallow. Nectar-thick liquids are liquids that have a slightly thicker consistency than water, which makes them easier for the client to swallow without choking or aspirating.
Options B, C, and D are not appropriate for a client with dysphagia on a pureed diet with nectar-thick liquids. Corn on the cob is a hard, crunchy food that is difficult to puree, while a hamburger and a salad are both difficult to make into a smooth consistency. These foods could pose a choking or aspiration risk for the client.
Correct Answer is C
Explanation
The correct answer is choice C. Cyanosis. Cyanosis is a medical emergency and requires immediate action by the nurse. It indicates that the client is not receiving adequate oxygenation and can lead to respiratory failure if not addressed promptly. Pallor (Option A) and erythema (Option D) are concerning but are not immediate priorities compared to cyanosis. Jaundice (Option B) may indicate liver dysfunction but is not an immediate priority unless it is associated with other symptoms such as severe abdominal pain or altered mental status.
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