Nurse logic
The nurse assesses Josh's vital signs. His respirations are rapid and shallow.
1. What is the best technique for the nurse to use to assess Josh's respirations accurately?
A. Observe chest expansion for 15 seconds and multiply by 4
B. Encourage Josh to breath as deeply and slowly as possible
C. Watch for nasal flaring and count the air exchanges with each movement
D. Place a hand on Josh's chest and count the hand motion D. Place a hand on Josh's chest and count the hand motion -
Rationale: This technique allows the nurse to observe and count the chest movement, even when respirations are shallow.
Josh's respirtory rate is 36.
2. How should the nurse describe Josh's respiratory pattern?
A. Eupnea
B. Bradypnea
C. Trachypnea
D. Orthopnea C. Trachypnea -
Rationale: A rapid respiratory rate, which is consistent with Josh's rate of 36. Normal respiratory rate for a school-aged child is 16-30 breaths per minute.
Because of Josh's dyspnea, the nurse is concerned that he may need to receive oxygen.
3. To determine the need for the application of a nasal cannula, which assessment is most important for the nurse to perform?
A. Measure oxygen saturation
B. Auscultate breathing sounds
C. Measure capillary refill
D. Observe chest excursion A. Measure oxygen saturation -
Rationale: Oxygen saturation provides important data about the percentage of hemoglobin that is saturated with oxygen - a valuable reflection of the client's overall oxygenation.
4. In assessing Josh's breathing sounds, the nurse should ask him to perform which action?
A. Hold his breath for fifteen seconds
B. Repeat the phrase, "ninety-nine"
C. Cough deeply after each breath
D. Breath deeply through the mouth D. Breath deeply through the mouth -
Rationale: Josh should be instructed to breathe slowly and deeply through a slightly opened mouth to allow best auscultation of breathing sound.
5. To measure capillary refill, the nurse must first
1. What is the best technique for the nurse to use to assess Josh's respirations accurately?
A. Observe chest expansion for 15 seconds and multiply by 4
B. Encourage Josh to breath as deeply and slowly as possible
C. Watch for nasal flaring and count the air exchanges with each movement
D. Place a hand on Josh's chest and count the hand motion D. Place a hand on Josh's chest and count the hand motion -
Rationale: This technique allows the nurse to observe and count the chest movement, even when respirations are shallow.
Josh's respirtory rate is 36.
2. How should the nurse describe Josh's respiratory pattern?
A. Eupnea
B. Bradypnea
C. Trachypnea
D. Orthopnea C. Trachypnea -
Rationale: A rapid respiratory rate, which is consistent with Josh's rate of 36. Normal respiratory rate for a school-aged child is 16-30 breaths per minute.
Because of Josh's dyspnea, the nurse is concerned that he may need to receive oxygen.
3. To determine the need for the application of a nasal cannula, which assessment is most important for the nurse to perform?
A. Measure oxygen saturation
B. Auscultate breathing sounds
C. Measure capillary refill
D. Observe chest excursion A. Measure oxygen saturation -
Rationale: Oxygen saturation provides important data about the percentage of hemoglobin that is saturated with oxygen - a valuable reflection of the client's overall oxygenation.
4. In assessing Josh's breathing sounds, the nurse should ask him to perform which action?
A. Hold his breath for fifteen seconds
B. Repeat the phrase, "ninety-nine"
C. Cough deeply after each breath
D. Breath deeply through the mouth D. Breath deeply through the mouth -
Rationale: Josh should be instructed to breathe slowly and deeply through a slightly opened mouth to allow best auscultation of breathing sound.
5. To measure capillary refill, the nurse must first