The nurse is assessing the client's respiratory system. Which ...

[karateprodigy]

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.

Question 2

While assessing the client, the nurse notes that the client has a productive cough. Based on this observation, which question is appropriate for the nurse to include in the focused interview?
 
  1. Have you been losing weight?
  2. How long have you been sick?
  3. Are you wheezing?
  4. Are you coughing up any mucus or phlegm?

[Jayson]

Answer to Question 1

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.

Answer to Question 2

Correct Answer: 4
The nurse must determine if the cough is productive or nonproductive. A moist cough is often associated with lung infections. The color and odor of any mucus or phlegm (sputum) is associated with specific diseases or problems. At this point, the client should not be questioned about weight loss. The client may not necessarily be sick. The client should be questioned about the cough during the focused interview and not about wheezing.