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: Asking about other drug allergies is relevant but secondary to understanding the penicillin allergy’s nature. Without clarifying the reaction’s severity (e.g., anaphylaxis vs. rash), the nurse cannot fully assess the risk, making this a less immediate response.
Choice B reason: Asking about the frequency of penicillin use does not address the nature or severity of the allergic reaction. This information is irrelevant to managing the allergy and ensuring patient safety, making it an inappropriate initial response.
Choice C reason: Asking the patient to describe their reaction to penicillin clarifies the type and severity of the allergy (e.g., rash, anaphylaxis). This informs safe medication administration and prevents adverse reactions, making it the most critical and appropriate response.
Choice D reason: Documenting the allergy is necessary but premature without understanding the reaction’s specifics. Assuming the allergy without verification could lead to incomplete charting or mismanagement, making this a less priority response compared to gathering details.
Correct Answer is C
Explanation
Choice A reason: Intelligence cannot be assessed in a 3-month-old, as cognitive abilities are not yet developed enough for evaluation. Sucking and grasping are innate behaviors driven by reflexes, not conscious thought, making this an incorrect assessment focus.
Choice B reason: Cerebral cortex function is immature in a 3-month-old, and sucking and grasping are primarily brainstem-mediated reflexes. These actions do not directly assess higher cortical functions like memory or reasoning, making this an incorrect choice.
Choice C reason: Sucking and grasping in a 3-month-old are primitive reflexes (sucking reflex and palmar grasp reflex), mediated by the brainstem. Assessing these evaluates normal neurological development, making this the correct focus of the nurse’s inquiry.
Choice D reason: While sucking involves Cranial Nerves V, VII, IX, and XII, and grasping involves spinal reflexes, the nurse is assessing the presence of these reflexes, not the cranial nerves directly. Reflex assessment is the primary focus, making this less precise.
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