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 A
Explanation
Choice A reason: Alcohol can interact with medications, altering their metabolism via liver enzymes (e.g., CYP450), and exacerbate conditions like liver disease or hypertension. This information is critical for safe treatment planning, making it the primary reason for inquiry.
Choice B reason: Assessing patient reliability is not the purpose of asking about alcohol use. This question focuses on clinical implications, not trustworthiness, as alcohol’s effects on health and medications are the priority, making this an incorrect rationale.
Choice C reason: Alcohol use is relevant even without an obvious drinking problem, as even moderate consumption can affect medication efficacy or disease progression. Dismissing this question unless a problem is evident overlooks potential risks, making this incorrect.
Choice D reason: Teaching all patients to avoid alcohol is not universally necessary, as moderate use may be safe for some. The inquiry aims to identify specific risks, like drug interactions, not to enforce blanket abstinence, making this an incorrect reason.
Correct Answer is B
Explanation
Choice A reason: Extension is straightening a joint, not moving toward the body’s midline. Adduction describes the arm moving inward, so this is incorrect for the described joint movement.
Choice B reason: Adduction is the movement of a limb toward the body’s midline, such as bringing the arm inward. This matches the nurse’s description, making it the correct term for the movement.
Choice C reason: Flexion is bending a joint, like elbow curling, not moving toward the midline. Adduction is specific to inward motion, so this is incorrect for the arm’s movement.
Choice D reason: Abduction is moving away from the midline, opposite to the described action. Adduction is the term for inward movement, so this is incorrect for the joint motion described.
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