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
Maintaining a healthy lifestyle is crucial for managing mild hypertension. One of the key lifestyle changes recommended for individuals with hypertension is reducing salt (sodium) intake.
The American Heart Association recommends limiting sodium intake to no more than 2,300 milligrams (about 2 grams) per day. By expressing the goal to decrease salt intake to 2 grams per day, the client demonstrates an understanding of the teaching.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
The client's symptoms are concerning for angina or a possible myocardial infarction (heart atack) and require immediate intervention. Nitroglycerin is a medication that can help relieve chest pain associated with cardiac events by dilating blood vessels and reducing the workload on the heart.
Therefore, the nurse should administer nitroglycerin as ordered by the provider. After administering nitroglycerin, the nurse should obtain an ECG to assess for any changes in cardiac rhythm or evidence of ischemia (lack of blood flow to the heart muscle).
The ECG can provide important diagnostic information and guide further treatment decisions.
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