The nurse is observing a student nurse performing a respiratory assessment on a client. Which statement indicates that the student nurse is performing the assessment correctly?
1. The student nurse has the client in either a sitting or lying position.
2. The client is placed in a sitting position and uncovered to the waist.
3. The client is placed in a sitting position with gown and blanket.
4. The client is placed in the semi-Fowler's position with gown removed.
2
Rationale 1: When performing a respiratory assessment, the client should be sitting or in a lying position; however, the client should be uncovered.
Rationale 2: For a complete respiratory assessment, the client should be sitting and uncovered to the waist.
Rationale 3: Having the client in a sitting position is correct; however, the client needs to be uncovered in order to adequately assess.
Rationale 4: A semi-Fowler's position is not appropriate when assessing a client's respiratory system.
Global Rationale: For a complete respiratory assessment, the client should be sitting and uncovered to the waist. When performing a respiratory assessment, the client should be sitting or in a lying position; however, the client should be uncovered. Having the client in a sitting position is correct; however, the client needs to be uncovered in order to adequately assess. A semi-Fowler's position is not appropriate when assessing a client's respiratory system.
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