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.

Answer and Explanation

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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Free Nursing Study Resources

Correct Answer is A

Explanation

Wash hands with soap and water for 20 seconds: Washing hands with soap and water is the preferred method for hand hygiene in most situations, especially when hands are visibly soiled or contaminated with body fluids. The CDC recommends washing hands for at least 20 seconds, ensuring that all surfaces of the hands, including the back of the hands, between the fingers, and under the nails, are thoroughly cleaned.

Artificial nails should not be worn when performing direct client care: Artificial nails, including nail extensions and overlays, should be avoided when providing direct client care. The wearing of

artificial nails can increase the risk of bacterial colonization and make proper hand hygiene more challenging. Short, natural nails without nail polish are recommended for healthcare workers to ensure effective hand hygiene and reduce the risk of infection transmission.

Wear sterile gloves when in contact with body fluids: Sterile gloves are indicated when there is a need for an aseptic technique or when in contact with sterile body sites or invasive procedures.

However, for routine patient care and non-sterile procedures, non-sterile disposable gloves are typically sufficient. The use of gloves does not replace the need for proper hand hygiene before and after glove use.

Use alcohol-based cleanser when hands are visibly soiled: Alcohol-based hand sanitizers are effective in killing many types of germs when used correctly. However, they are not as effective when hands are visibly soiled or contaminated with body fluids. In such cases, washing hands with soap and water is recommended to ensure proper cleansing and removal of visible dirt or contaminants.

A. Administer an anti-anxiety medication. B. Explore behaviors that have helped to reduce the client's anxiety in the past. C. Minimize environmental stimuli in the client's surroundings. D. Explain to the client that anxiety causes physical manifestations

Correct Answer is C

Explanation

The client is experiencing palpitations and a sense of impending doom, which may indicate a heightened state of anxiety or a panic attack. Minimizing environmental stimuli can help create a calming and safe environment for the client. By reducing noise, bright lights, and other potentially distressing stimuli, the nurse can create a more soothing atmosphere that may help alleviate the client's anxiety.

While exploring behaviors that have helped to reduce the client's anxiety in the past and explaining to the client that anxiety causes physical manifestations are important actions, they may not provide immediate relief or address the client's immediate distress.

Administering an anti-anxiety medication may be considered if the client's symptoms persist or worsen, but it is not the first action to be taken. The nurse should prioritize non-pharmacological interventions and create a supportive environment before considering medication administration.

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