A patient is breathing rapidly. The nurse's most appropriate ...

[azncindy619]

A patient is breathing rapidly. The nurse's most appropriate response would be to:
 
  A. take the patient's radial pulse.
  B. count the patient's respirations.
  C. take a measurement of the patient's oxygen saturation level.
  D. ask the patient if any situations have contributed to this response.

Question 2

A patient in balanced suspension traction can have the head of the bed raised only 30 degrees. To promote normal elimination, patients need to assume a sitting position to:
 
  A. stimulate the peristaltic movement.
  B. contract the thigh muscles used to defecate.
  C. strengthen the internal and external sphincters.
  D. exert intra-abdominal pressure, which aids in defecation.

[kaillie]

Answer to Question 1

C
The radial pulse indicates cardiac rate. Counting respirations will enable you to assess if this response is normal or abnormal for the patient. A number of conditions will cause both normal and abnormal increase in respiratory rate.

Answer to Question 2

D
Physiological factors critical to bowel function and defecation include normal GI tract function, sensory awareness of rectal distention and rectal contents, voluntary sphincter control, and ade-quate rectal capacity and compliance. Contraction of abdominal muscles at times aids in defeca-tion. When stool reaches the rectum, the internal sphincter relaxes.

[azncindy619]

TYSM

[mjenn52]

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