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?
Place the client in a supine position.
Observe the movements of the client's chest wall.
Inform the client when beginning to observe his respirations.
Count the client's respirations for 15 seconds.
The Correct Answer is B
To accurately assess the client's respirations, the nurse should observe the movements of the client's chest wall. This can be done by visually inspecting the rise and fall of the chest or by placing a hand on the client's chest to feel the movements. This allows the nurse to assess the depth, rhythm, and effort of the client's breathing. I
It is important to observe the client's respirations without informing them, as this may cause the client to alter their breathing pattern consciously.
Counting the client's respirations for a full minute (rather than 15 seconds) provides a more accurate measurement.
Placing the client in a supine position may not be necessary for assessing respirations, as it is primarily focused on observing the chest movements.
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Related Questions
Correct Answer is C
Explanation
Thyrotoxicosis refers to a state of excess thyroid hormone in the body, which can occur as a result of excessive levothyroxine dosage or other causes. Nervousness is a common symptom of thyrotoxicosis, characterized by an excessive or uncontrollable feeling of anxiety or restlessness. It is important for the client to report this symptom to the healthcare provider because it may indicate an imbalance in thyroid hormone levels and may require adjustment of the medication dosage.
Polyuria, which refers to increased urination, is not a specific symptom of thyrotoxicosis. It can occur due to various factors unrelated to thyroid function.
Pruritus, or itching, is not a common symptom of thyrotoxicosis. It may be associated with other conditions or causes.
Cough is not typically associated with thyrotoxicosis. It is more commonly related to respiratory or pulmonary conditions rather than thyroid dysfunction.
Correct Answer is A
Explanation
a. Support the client's decision to stop the treatment.
As a nurse, it is important to respect the client's autonomy and right to make decisions about their own care. The decision to stop dialysis treatment is a personal one and should be respected by the healthcare team. The nurse should support the client's decision and provide information and resources to help the client manage symptoms and maintain comfort during the end-of-life process.
It is not appropriate for the nurse to suggest that the client discuss the decision with her family or to discuss alternative treatment methods, as these decisions should be made by the client in conjunction with their healthcare provider.
It may be appropriate to offer spiritual or emotional support to the client, but this should be based on the client's preferences and not imposed upon them by the healthcare team.
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