The nurse is concerned about a client with an increasing respiratory rate now at 24. Which action by the nurse reflects data gathering and clinical reasoning?
Ask the client to perform IS.
Notify the provider.
Obtain vitals and pulse ox.
Call rapid response.
The Correct Answer is C
A. Ask the client to perform IS: Encouraging incentive spirometry promotes lung expansion and prevents atelectasis, but it is an intervention rather than an assessment. Performing this action without first gathering additional clinical data does not provide information about the underlying cause of the increased respiratory rate or the client’s oxygenation status.
B. Notify the provider: Notifying the provider is a critical step when a patient’s condition may be deteriorating, but it occurs after the nurse has collected and interpreted objective data. Immediate reporting without first assessing vital signs and oxygenation may result in incomplete communication and delay targeted interventions.
C. Obtain vitals and pulse ox: Gathering vital signs, including respiratory rate, heart rate, blood pressure, and oxygen saturation, allows the nurse to quantify the client’s current status and identify potential hypoxia, infection, or other causes of tachypnea. This reflects both data collection and clinical reasoning, forming the basis for prioritizing further interventions and communicating effectively with the provider.
D. Call rapid response: Activating the rapid response team is appropriate for signs of acute deterioration, but an increased respiratory rate of 24 alone may not meet criteria for immediate team activation. The nurse should first gather additional assessment data to determine the severity of the situation and the appropriate level of intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Acute pain: Severe pain directly impacts the client’s ability to participate in rehabilitation, ambulate safely, and perform activities of daily living. Uncontrolled pain can also lead to physiologic stress responses, such as increased heart rate, blood pressure, and respiratory rate, which can compromise recovery. Addressing acute pain is the priority because it influences both safety and overall healing outcomes.
B. Risk for infection: While post-surgical infection is an important concern, it is a potential problem rather than an immediate issue. Infection risk requires monitoring and preventive measures but does not pose the same immediate threat to safety and functional ability as severe, uncontrolled pain.
C. Surgical repair: This is a medical intervention rather than a nursing diagnosis. While important, it does not reflect the client’s current priority need from a nursing perspective, which focuses on physiological and functional safety.
D. Impaired mobility: Impaired mobility is relevant in this post-op patient; however, mobility is currently limited by severe pain. Addressing pain first facilitates safe participation in mobility activities and rehabilitation, making it the more urgent concern.
Correct Answer is C
Explanation
A. Ask his wife: While family members may help interpret the client’s needs, relying solely on a family member does not promote independent communication or respect the client’s autonomy. It may also lead to misinterpretation if the family cannot accurately convey the client’s intentions.
B. Use hand signals: Hand gestures can provide some nonverbal communication, but they are limited and may be misinterpreted, especially if the client’s motor skills are impaired after a stroke. Hand signals alone are not sufficient for complex or specific communication needs.
C. Use a communication board: Communication boards allow clients with expressive aphasia to point to letters, words, or pictures to convey messages. This method accommodates both verbal and cognitive limitations, facilitates more precise communication, and encourages client autonomy while reducing frustration and miscommunication.
D. Speak slowly and clearly: Speaking slowly and clearly may improve understanding for clients with receptive aphasia, but it does not enable a client with expressive aphasia to communicate their needs effectively. The client’s inability to speak requires an alternative communication method rather than adjustments to speech alone.
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