Before actually counting a client's respirations, the nurse should FIRST determine which of the following?
a. The client is fully aware that the respiratory rate is being measured.
b. There is bilateral movement of the client's chest wall or any irregularity in movement.
c. The client is lying on either side.
d. There is evidence of cyanosis.
B
Respiration assessment is the measurement of the breathing pattern. Assessment of the movement of the chest wall is done initially to determine if there is bilateral movement of the chest wall or any irregularity in movement.
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The family of a patient who experienced a stroke after percutaneous coronary revascularization asks the nurse what caused the stroke to occur. How should the nurse respond to the family?
1. "A stroke could have been caused by clot particles from the procedure." 2. "Stroke is usually caused by ruptured plaque inside the coronary artery." 3. "Stroke is caused by heart failure." 4. "No one knows what causes strokes."
A client has been prescribed Premarin. What medication information should the nurse provide?
1. "You may notice a decrease in your libido while on this medication." 2. "If you notice pain in your abdomen that goes through to your back, be certain to notify the clinic." 3. "Do not become pregnant while on this drug." 4. "If you add the herbal black cohosh to this therapy the results will be better." 5. "This medication will help prevent cardiovascular disease."
The best example of an appropriate nursing assumption is:
1. Clients will make their needs and wants known to the staff 2. Clients require a quiet, darkened environment in which to sleep 3. Prompt administration of pain medication is an expectation of a postoperative client 4. A client recently diagnosed with cancer will want family present when discussing treatment options
The nurse identifies deficient knowledge regarding warfarin when a patient states, "I will:
1. avoid participating in contact sports." 2. take my medication in the early evening each day." 3. take aspirin if I get a headache." 4. contact my physician if I develop excessive bruising."