A patient has a hemoglobin of 7.1 g/dL. The nurse understands that anemia is likely to result in which of the following?

Choice A reason: Not touching the patient until assessment completion is unnecessary, as gentle touch may be required to feel pulse or position the patient. Avoiding touch does not ensure accurate respiratory assessment and may hinder observation of chest movement, per respiratory assessment guidelines.

Choice B reason: Informing the patient that respirations are being counted may alter their breathing pattern due to awareness, leading to inaccurate rates. Conscious breathing can increase or decrease the rate, compromising the assessment’s validity, per clinical observation techniques.

Choice C reason: Obtaining respirations without the patient knowing ensures an accurate rate, as awareness can cause altered breathing. Discreetly counting while appearing to check the pulse preserves natural respiration, aligning with standard assessment techniques for reliable respiratory rate data, per nursing practice.

Choice D reason: Estimating respirations is inappropriate, as it lacks precision, risking inaccurate data. Counting respirations for 30-60 seconds provides an objective rate, critical for identifying abnormalities like tachypnea or bradypnea, ensuring proper clinical decision-making, per respiratory assessment standards.

Choice A reason: Assessing involves collecting data, like vital signs or skin condition, to identify patient needs. Turning a client every 2 hours follows an established plan to prevent pressure ulcers, not data collection. Assessment informs care plans, but turning is an action, not an evaluation of physiological status, making this incorrect.

Choice B reason: Planning involves setting goals and interventions, like scheduling turns to prevent pressure ulcers. Turning a client every 2 hours is executing that plan, not creating it. Planning addresses skin integrity and tissue perfusion needs, but the act of turning is the implementation phase, making this an incorrect choice.

Choice C reason: Implementing is the execution of the care plan, such as turning a client every 2 hours to prevent pressure ulcers. This action maintains skin integrity by reducing pressure on tissues, promoting blood flow and oxygenation. It follows the plan’s directives, aligning with the nursing process’s action phase, making this the correct choice.

Choice D reason: Evaluating assesses the effectiveness of interventions, like checking skin integrity after turning. Turning a client every 2 hours is the intervention itself, not its evaluation. Evaluation measures outcomes, like reduced pressure ulcer risk, but the act of turning is implementation, addressing tissue perfusion, making this incorrect.