Answer to Question 1
B
Do not let a patient know that respirations are being assessed. A patient who is aware of the assessment can alter the rate and depth of breathing. Respirations are the easiest of all vital signs to assess, but they are often the most haphazardly measured. Do not estimate respirations. Accurate measurement requires observation and palpation of chest wall movement.
Answer to Question 2
D
The cause of the patient's problem will help guide the nurse to the proper nursing intervention. If the patient has a problem with verbal communication, then the nurse should choose an intervention that will address the problem. Providing the patient with a writing board will allow the patient to communicate by writing because the patient is unable to communicate verbally at this time. Obtaining an interpreter might be an appropriate intervention if the patient spoke a foreign language. Assisting with swallowing exercises will help the patient with swallowing, which is a different nursing diagnosis from Impaired verbal communication. Asking the family to provide a sitter at all times is many times unrealistic and does not promote the patient's independence, as does providing a writing board.
In the communication technique of collaborating, the nurse sends the message that the nurse and pati
Assessing Lung Sounds
Teaching patient discharge instructions
Example of a patient statement.
Preoperative and Postoperative Patient Instructions
Instructing a Patient to Use Crutches Correctly