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
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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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
A. Protect the muscles of the lower extremities from atrophy:
This statement is not the primary purpose of sequential compression devices (SCDs) and compression stockings. While these devices can help maintain muscle tone by promoting blood circulation, their primary function is to prevent blood pooling and reduce the risk of deep vein thrombosis (DVT).
B. Keep the blood from pooling in lower extremities to avoid clots:
This is the correct purpose of sequential compression devices and compression stockings. They are designed to promote venous return and prevent blood from pooling in the lower extremities, thereby reducing the risk of blood clots, especially in individuals at risk for deep vein thrombosis (DVT).
C. Keep the patient from getting sores on the skin:
Preventing sores on the skin is not the primary purpose of these devices. While improved circulation may contribute to skin health, preventing skin sores is not the primary therapeutic goal of SCDs and compression stockings.
D. Keep the patient’s joints in working order:
Maintaining joint function is not the primary purpose of sequential compression devices and compression stockings. These devices primarily focus on promoting venous circulation and preventing complications related to blood pooling and clot formation.
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