The nurse needs to assess a client's respiratory status. Which ...

[armygirl]

The nurse needs to assess a client's respiratory status. Which client position would be the best for this assessment?
 
  1. Prone
  2. Semi-Fowler's
  3. Side-lying
  4. Supine

Question 2

The RN assesses a client who is recovering from femoral popliteal bypass surgery and discovers that it is difficult to assess the dorsalis pedis pulses. Which nursing intervention would be most appropriate for the nurse to use?
 
  1. Ask another nurse to assess the pulses.
  2. Document the findings.
  3. Obtain a Doppler ultrasound stethoscope.
  4. Wait and try again later.

[EAN94]

Answer to Question 1

Correct Answer: 2
Rationale 1: The prone position increases the volume of blood inside the thoracic cavity and compresses the chest, compromising the client's respirations.
Rationale 2: Persons in a semi-Fowler's position will better aid themselves and the nurse to assess their respiratory status.
Rationale 3: The side-lying position increases the volume of blood inside the thoracic cavity and compresses the chest, compromising the client's respirations.
Rationale 4: The supine position increases the volume of blood inside the thoracic cavity and compresses the chest, compromising the client's respirations.

Answer to Question 2

Correct Answer: 3
Rationale 1: If one nurse is having difficulty with the pulse and accuracy, getting another nurse is not going to be the best choice.
Rationale 2: Just documenting the findings does not address the problem of getting an accurate pulse reading.
Rationale 3: Obtaining a Doppler ultrasound stethoscope is the appropriate action to take. The Doppler will ensure accuracy by helping to exclude environmental sounds.
Rationale 4: Waiting until later may be harmful to the client, creating an unsafe environment.

[armygirl]

TYSM

[amandalm]

Gracias!