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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "It takes 2 months of scheduled use before this medication is effective." is incorrect. Montelukast is generally effective within 1-2 weeks of starting the medication, not 2 months.
B. "I will give this medication to my child once daily in the evening." is correct. Montelukast is usually administered once daily, in the evening, to help prevent asthma symptoms.
C. "I can stop giving my child this medication if he is taking a steroid." is incorrect. Montelukast and steroids can be used together to manage asthma, but stopping montelukast is not recommended unless advised by the healthcare provider.
D. "I will give this medication to my child every 2 hours if he is wheezing." is incorrect. Montelukast is a maintenance medication and should not be used as a rescue treatment for acute wheezing. For acute symptoms, a short-acting bronchodilator is typically used.
Correct Answer is D
Explanation
A. Acetaminophen: Acetaminophen is an effective analgesic for mild to moderate pain but may not be sufficient for managing postoperative pain after a total knee arthroplasty, where moderate to severe pain is common.
B. Ibuprofen: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID. that can be used for pain, but it may not be the best choice for moderate to severe postoperative pain, as opioids are typically more effective for this type of pain.
C. Celecoxib: Celecoxib is an NSAID, and like ibuprofen, it can be useful for managing pain, but for a postoperative pain level of 6, a stronger medication like an opioid may be more appropriate.
D. Oxycodone: Oxycodone is an opioid analgesic, and it is typically used to manage moderate to severe pain, such as the pain a patient may experience after total knee arthroplasty. It would be the most appropriate choice for a pain level of 6 on a 0–10 scale.
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