Author Question: The nurse is assessing the patient's respirations. Which action by the nurse is most appropriate? ... (Read 37 times)

vHAUNG6011 · **on:** Jul 22, 2018

The nurse is assessing the patient's respirations. Which action by the nurse is most appropriate?

a. Inform the patient that she is counting respirations.
b. Do not touch the patient until completed.
c. Obtain without the patient knowing.
d. Estimate respirations.

Question 2

The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement?

a. Place the tips of the first two fingers over the groove along the thumb side of the patient's wrist.
b. Place the tips of the first two fingers over the groove along the little finger side of the patient's wrist.
c. Place the thumb over the groove along the little finger side of the patient's wrist.
d. Place the thumb over the groove along the thumb side of the patient's wrist.

cloud · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: C
Do not let a patient know that you are assessing respirations. A patient aware of the assessment can alter the rate and depth of breathing. Assess respirations immediately after measuring pulse rate, with your hand still on the patient's wrist as it rests over the chest or abdomen. Respirations are the easiest of all vital signs to assess, but they are often the most haphazardly measured. Do not estimate respirations.

Answer to Question 2

ANS: A
Place the tips of the first two or middle three fingers of the hand over the groove along the radial or thumb side of the patient's inner wrist. Fingertips are the most sensitive parts of the hand to palpate arterial pulsation. The thumb has a pulsation that interferes with accuracy. The groove along the little finger is the ulnar pulse.