A nurse is monitoring a client who is postoperative. Which of the following actions should the nurse take when collecting data about the client's respirations?
Count the client's respirations for 15 seconds.
Place the client in a supine position.
Inform the client when beginning to observe his respirations.
Observe the movements of the client's chest wall.
The Correct Answer is D
A. "Count the client's respirations for 15 seconds" is incorrect. The nurse should count respirations for a full 60 seconds to ensure accuracy, especially in postoperative clients, as irregularities may be more easily detected with a longer observation period.
B. "Place the client in a supine position" is not necessary. While the position of the client can affect respiration, the nurse does not need to place the client in a supine position specifically to assess respirations. The client should be in a comfortable position that allows for adequate observation.
C. "Inform the client when beginning to observe his respirations" is incorrect. The client should not be aware that their respirations are being counted, as awareness can alter their breathing patterns and lead to inaccurate data.
D. "Observe the movements of the client's chest wall" is correct. Observing the chest wall allows the nurse to assess the rate, depth, and rhythm of respirations, as well as any signs of distress or abnormal patterns, which is crucial for monitoring postoperative respiratory status.
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Correct Answer is D
Explanation
A. Using hot water to wash hands is incorrect. Hot water can cause skin irritation and is not necessary for effective hand hygiene. The water temperature should be comfortable for the person washing their hands, whether it is warm or cool.
B. Applying friction to hands for 10 seconds is incorrect. Hand hygiene should be done for at least 20 seconds, not just 10 seconds, to effectively remove contaminants.
C. Drying hands starting from forearm to fingers is incorrect. Hands should be dried starting from the fingers to the forearms to avoid contamination from dripping water on the hands after washing. The goal is to maintain clean hands throughout the drying process.
D. Interlacing the fingers while rubbing hands together is correct. Interlacing the fingers and rubbing them together ensures that all surfaces of the hands, including between the fingers, are properly cleaned. This method is recommended in the CDC hand hygiene guidelines for thorough washing.
Correct Answer is D
Explanation
A. "Soak in a bathtub of hot water." – Soaking in hot water is not recommended during pregnancy, as it can cause overheating and affect blood flow, potentially leading to complications such as fainting or preterm labor.
B. "Obtain a prescription for pramipexole." – Pramipexole is a medication primarily used for Parkinson’s disease and restless legs syndrome, and it is not typically prescribed to address sleep disturbances during pregnancy.
C. "Use a transcutaneous electrical nerve stimulator (TENS)." – TENS is not generally recommended for treating sleep disturbances during pregnancy. It is more commonly used for pain management.
D. "Lie on your left side with your top leg forward." – Lying on the left side with the top leg forward is a recommended sleeping position during pregnancy, as it can improve blood circulation to the fetus and reduce pressure on the vena cava, which can help improve sleep and comfort
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