The patient appears to be breathing faster than before. Which of the following actions should the nurse take first?
a. Ask the patient if there have been any stressful visitors.
b. Have the patient lie down.
c. Count the rate of respirations.
d. Take the radial pulse.
C
Feedback
A Stress may increase an individual's respiratory depth and rate as a result of sympathetic stimulation.
B Lying flat prevents full chest expansion.
C The first action the nurse should take is to assess the patient's respiratory rate. The nurse can then determine if it is within normal limits and will be able to compare it with the previous measurement to determine if the patient is breathing faster than before.
D The nurse should count the respirations. Based on these findings, the nurse may or may not need to take the patient's pulse. Assessing the pulse will not verify whether the patient is breathing faster than before.
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