The charge nurse is observing a newly licensed nurse conduct an ...

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The charge nurse is observing a newly licensed nurse conduct an admission assessment on a client with asthma. Which action by the newly licensed nurse requires immediate intervention?
 
  A) The newly licensed nurse is observed obtaining the pulse oximetry reading 10 minutes after the client used an albuterol inhaler.
  B) The newly licensed nurse is observed continuing to ask the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment.
  C) The newly licensed nurse is observed assessing the client's thoracic wall, skin, and nail beds.
  D) The newly licensed nurse is observed auscultating breath sounds with a stethoscope.

Question 2

The nurse assigned to the newborn nursery is conducting shift assessments. While assessing one newborn, the nurse notes the respiratory rate is 52 breaths per minute. Which action by the nurse is appropriate?
 
  A) Notify the healthcare provider of this assessment finding.
  B) Obtain an arterial blood gas for further respiratory assessment.
  C) Begin monitoring the respiratory rate every 5 minutes.
  D) Continue to monitor the newborn per facility policy.

[parshano]

Answer to Question 1

Answer: B

The charge nurse should intervene immediately if the nurse observes the client is demonstrating impairment at or near respiratory failure; the client will not be able to respond to questions. Assessment questions should be tailored and asked of any family member or friend accompanying the client. The client's physician should be notified immediately on the client's arrival to the unit. The immediate concern is to return respiratory status as near to normal as possible. Although the pulse oximetry reading may not be a true indicator of the level of respiratory distress of the client because of the use of an albuterol inhaler within 30-60 minutes of this assessment, it is still an appropriate action for the newly licensed nurse to take and does not require the charge nurse to intervene immediately. The charge nurse may speak to the newly licensed nurse later with regard to this assessment. Assessing the client's thoracic wall, skin, and nail beds is an appropriate action at this time. Auscultating the client's breath sounds with the use of a stethoscope is appropriate.

Answer to Question 2

Answer: D

A respiratory rate of 52 breaths per minute is a normal finding in a newborn. Respiratory rates are highest and most variable in newborns. The respiratory rate of a neonate or newborn is 30-60 breaths per minute.