What is the best time for the nurse to measure a patient's respirations?
When measuring the pulse
When auscultating
When interviewing the patient
When sleeping
The Correct Answer is D
Choice A reason: Measuring respirations during pulse assessment can lead to inaccurate counts, as patients may alter their breathing when aware of pulse measurement. Conscious awareness often causes irregular or controlled breathing, which does not reflect the true respiratory rate, making this an unreliable time.
Choice B reason: Auscultation involves listening to lung or heart sounds, which requires patient cooperation and often affects breathing patterns. Patients may consciously modify their respirations during this process, leading to inaccurate respiratory rate measurements, rendering this an unsuitable time for assessment.
Choice C reason: Interviewing involves patient interaction, which can influence breathing due to speech or emotional responses. This conscious activity often results in irregular or controlled breathing patterns, making it an unreliable time to accurately measure the patient’s natural respiratory rate.
Choice D reason: Measuring respirations when the patient is sleeping ensures an undisturbed, natural breathing pattern, as the patient is unaware of the assessment. This allows the nurse to count the respiratory rate accurately, reflecting the true resting state, making it the optimal time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Normal pupil findings include equal size (2–5 mm) and brisk reaction to light bilaterally. A fully dilated, nonreactive right pupil with a reactive left pupil indicates a neurological abnormality, not a normal finding, as it suggests significant brain dysfunction.
Choice B reason: Rechecking findings is prudent, but the described pupil changes—unilateral dilation and nonreactivity—are classic signs of a serious condition. Delaying action by only rechecking could miss critical intervention timing, as these findings strongly indicate a neurological emergency.
Choice C reason: A unilaterally dilated, nonreactive pupil with a normal contralateral pupil suggests increased intracranial pressure, often from a hematoma or swelling compressing the oculomotor nerve (Cranial Nerve III). This causes pupil dilation and loss of light reflex, requiring urgent intervention.
Choice D reason: Brainstem injury typically causes bilateral pupil changes, such as fixed, pinpoint, or dilated pupils, due to damage to brainstem nuclei. The unilateral findings here are more indicative of focal pressure (e.g., hematoma) than diffuse brainstem injury, making this less likely.
Correct Answer is D
Explanation
Choice A reason: Convergence and pupil constriction are accommodation reflexes, not corneal light reflex, which tests alignment. Light reflection symmetry indicates eye alignment, so this incorrect for the reflex’s purpose.
Choice B reason: Pupil constriction is a pupillary reflex, not corneal light reflex. The corneal reflex involves light reflection on corneas, assessing alignment, not pupil response, so this is incorrect.
Choice C reason: Macular focus is related to visual acuity, not corneal reflex, light reflex, which checks eye alignment via light reflection. Symmetric reflection is key, so this incorrect for the reflex’s indication.
Choice D reason: A normal corneal reflex shows light reflecting in the same spot on both corneas, indicating proper eye alignment. This is the definition of the reflex, making it the correct choice for eye assessment.
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