The nurse is assessing the client's respiratory system. Which method will result in the most accurate assessment of the client's respiratory rate?
1. The nurse should place a hand on the client's chest to count respirations accurately.
2. The nurse should inform the client that the nurse is counting the client's respirations.
3. The nurse should count only the respirations that are audible.
4. The nurse should count the respirations in an unobtrusive manner without informing the client.
Correct Answer: 4
If a client knows his respirations are being counted, it may alter the normal breathing pattern. Though laying a hand on the client's chest allows the nurse to feel the rise and fall of the chest, this may be considered an intrusive move and might increase the client's level of anxiety, which may affect the respiratory rate. The nurse should not inform the client about this portion of the assessment. Not all clients have audible respiratory cycles, and this would not be an effective method for accuracy.
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