The client appears to be breathing faster than before. Which of the following actions should the nurse take first?
a. Ask the client if there have been any stressful visitors.
b. Have the client lie down.
c. Count the rate of respirations.
d. Take the radial pulse.
C
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 with the previous measure-ment to determine if the client is breathing faster than before.
Stress may increase an individual's respiratory depth and rate as a result of sympathetic stimula-tion.
Lying flat prevents full chest expansion.
The nurse should count the respirations. Based on these findings, the nurse may or may not need to take the client's pulse. Assessing the pulse will not verify whether the client is breathing faster than before.
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