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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a.Pancrelipase does not directly impact respiratory function. It is an enzyme replacement therapy used to aid digestion by compensating for the lack of pancreatic enzymes, not to improve lung function.
b.Cystic fibrosis affects sodium and chloride transport, leading to higher sodium levels in sweat. However, pancrelipase does not affect sodium excretion; it focuses on aiding digestion.
c.Pancrelipase helps with the digestion and absorption of fats and fat-soluble vitamins (A, D, E, K). Vitamins B and C are water-soluble and are not typically affected by the enzyme therapy used for fat digestion.
d.This is the correct answer. Pancrelipase contains enzymes (lipase, protease, and amylase) that help break down fats, proteins, and carbohydrates. In cystic fibrosis, pancreatic enzyme production is often insufficient, leading to malabsorption and steatorrhea (excessive fat in the stools). By providing the necessary enzymes, pancrelipase helps improve the digestion and absorption of dietary fats, reducing the fat content in the stools.
Correct Answer is D
Explanation
a.This is not recommended. The central tip of the finger is more sensitive and has more nerve endings, which can cause more pain. The recommended site for blood glucose testing is the side of the fingertip, as it is less sensitive and provides an adequate blood sample.
b. While it is not necessary to wear sterile gloves for routine capillary blood glucose monitoring, it is important to ensure that the nurse's hands are clean. Wearing clean gloves helps maintain infection control practices.
c. After puncturing the selected site, the nurse should gently squeeze the finger to create a small drop of blood. The first drop of blood should be wiped away, and subsequent drops should be used for the glucose test. This ensures that the sample is fresh and not contaminated with tissue fluid.
d.Keeping the finger in a dependent position (hanging down) helps improve blood flow to the fingertip, making it easier to obtain a sufficient blood sample. This can help ensure an accurate glucose reading.
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