The client appears to be breathing faster than before. The nurse should:
1. Ask the client if he has felt stressful
2. Have the client lay down on the bed
3. Count the client's rate of respirations
4. Palpate the client's own radial pulse
ANS: 3
The first action the nurse should take is to assess the client's respiratory rate. The nurse can then determine if it is within normal limits and will be able to compare it to the previous measurement to determine if the client is breathing faster than before. Stress may increase an individual's res-piratory rate. The nurse should first make the objective measurement of the client's rate. Having the client lay down may decrease a client's respiratory rate, but the nurse should first assess the client before implementing any nursing measures. The nurse should count the respiratory rate. Based on these findings the nurse may or may not need to take the client's pulse. Assessing the pulse will not verify if the client is breathing faster.
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