The nurse is performing a respiration assessment on her client. The nurse begins counting the respirations when the second hand on the clock is at 12. When the nurse looks at the chest of the client he is exhaling. The client then continues to inhale and exhale 9 times. When the second hand on the clock is just past 5 the patient begins to inhale. When the second hand reaches the 6 the client has not exhaled. What would the nurse record in the chart as this client’s respiratory rate?

20 bpm

10 bpm

09 bpm

18 bpm

Answer and Explanation

The Correct Answer is B

A. 20 bpm: This is twice the calculated rate, so it's significantly higher than observed.

B. 10 bpm: This matches closely with the calculated rate of approximately 10.23 breaths per minute.

The scenario describes the nurse counting the client's breaths starting from when the second hand of the clock was at 12 and ending just past 5, and the client completed 9 breaths during this time frame.

Counting Period:

From just past 12 to just past 5 on the clock, the time span is approximately 53 seconds.

Number of Breaths:

The client completed 9 breaths within this time frame.

Now, to calculate the respiratory rate:

Respiratory rate = (Number of breaths / Time in minutes)

Respiratory rate = (9 breaths / 0.88 minutes) (53 seconds converted to minutes)

After calculation, the respiratory rate is approximately 10.23 breaths per minute.

C. 09 bpm: This is a lower value than observed and doesn't align with the counted breaths.

D. 18 bpm: This is close to double the observed rate, which doesn't match with the counted breaths within the time frame.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Discard the bottle of saline and obtain a new bottle:

Sterility is crucial when performing a sterile procedure. If the saline solution has been opened for 48 hours, it may no longer be considered sterile. The nurse's priority is to use a fresh, sterile bottle of saline to ensure aseptic technique during the dressing change.

B. Lip the bottle of saline over the trash before pouring into the field:

Lipping the bottle over the trash is not a recommended practice. Pouring the saline over a sterile field is the appropriate way to maintain the sterility of the solution.

C. Pour the saline at least 6 inches above the sterile field:

While pouring from a height can help generate a flow without contamination, the priority in this situation is to address the sterility of the saline. It's crucial to start with a new, unopened bottle.

D. Be sure the label is facing the palm before pouring:

The orientation of the label is not the primary concern in this scenario. The primary concern is the sterility of the saline solution.

A. The nurse should place his or her feet close together side by side to make themselves have a good center of gravity to assist the patient to the floor. B. The nurse should rock his or her pelvis out and try to hold the patient up to prevent falling. C. The nurse should grasp the gait belt and push the client’s body backward away from his or her body. D. The nurse should use the patients gait belt to gently slide the client down his or her body to the floor.

Correct Answer is D

Explanation

A. Placing the nurse's feet close together side by side to have a good center of gravity:

While maintaining a good center of gravity is important, in a falling situation, it's crucial to prioritize the client's safety over the nurse's stability. This option doesn’t address the prevention of the client’s fall.

B. Rocking the nurse's pelvis out and trying to hold the patient up to prevent falling:

Attempting to hold the patient up during a fall may put both the nurse and the client at risk of injury.

C. Grasping the gait belt and pushing the client’s body backward away from the nurse's body:

Pushing the client backward could cause the client to lose balance and fall in an uncontrolled manner.

D. Using the patient's gait belt to gently slide the client down the nurse's body to the floor:

This is the recommended action as it allows for a controlled descent to the floor, minimizing the impact of the fall and reducing the risk of injury to both the client and the nurse.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse on the progressive care unit is preparing to perform a sterile wet to dry dressing change on a client with a sacral pressure ulcer. The nurse notes that the sterile saline at the bedside is marked as opened 48 hours ago. What is the nurse’s priority action?

Correct Answer is A

Explanation

A nurse is ambulating a client who catches her foot on the bed frame and begins to fall. Which of the following is an accurate step to prevent or minimize damage from this fall?

Correct Answer is D

Explanation

The physician’s admitting orders indicate that the client is to be placed in a High Fowler’s position. Upon positioning this client, how much will the nurse elevate the head of the bed?

The nurse is applying a wrist restraint on a client who has pulled out his IV multiple times. How should the nurse secure this device?

The nurse is providing oral care for a client who is weak, drowsy, and unable to take anything by mouth (NPO). Which of the following would the nurse implement when performing appropriate oral care for this client?

A nurse is administering enoxaparin 40mg subcutaneous to a client for prevention of blood clots when the client suddenly moves causing the needle to exit the client’s tissue and stick the nurse’s finger. What is the nurse’s first priority action?

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair three times a day. Which of the following is the best action to transfer the client, for the first time, safely into the chair?