Vital Signs Measurement > Fundamentals
Exam Review
Respiratory Rate Measurement:
Total Questions : 5
Showing 5 questions, Sign in for moreA nurse is assessing a client's respiratory rate. Which technique should the nurse use to accurately measure the respiratory rate?
Explanation
Answer: a. Visual observation of chest movements
Explanation: The nurse should visually observe the client's chest movements to accurately measure the respiratory rate. This involves counting the number of complete inhalations and exhalations within a minute.
b. Auscultation of breath sounds is used to assess the quality of breath sounds but does not provide an accurate measurement of the respiratory rate.
c. Palpation of the client's abdomen is not the primary method for measuring the respiratory rate.
d. Using a respiratory rate monitor may provide an objective measurement, but visual observation is the most common and readily available technique.
A nurse is assessing a client's respiratory rate and finds it to be 8 breaths per minute. What action should the nurse take?
Explanation
Answer: c. Assess the client for signs of respiratory distress.
Explanation: A respiratory rate of 8 breaths per minute is below the normal range (12-20 breaths per minute) and may indicate respiratory depression or impairment. The nurse should assess the client for signs of respiratory distress and notify the healthcare provider for further evaluation and intervention.
a. Documenting the respiratory rate as normal would be inaccurate since it is below the normal range.
b. Initiating oxygen therapy is not the first-line intervention based solely on a low respiratory rate but requires a comprehensive assessment of the client's respiratory status.
d. Administering a bronchodilator medication is not appropriate solely based on a low respiratory rate without further assessment.
A nurse is assessing a client's respiratory rate using a pulse oximeter. Where should the nurse place the pulse oximeter sensor to accurately measure the respiratory rate?
Explanation
Answer: a. On the client's finger
Explanation: The pulse oximeter sensor is typically placed on the client's finger to accurately measure the respiratory rate. The sensor detects changes in blood volume and oxygen saturation, which correlate with respiratory cycles.
b. Placing the pulse oximeter sensor on the client's forehead is not the standard practice for measuring the respiratory rate.
c. Placing the pulse oximeter sensor on the client's chest is not necessary for measuring the respiratory rate as it primarily assesses oxygen saturation.
d. Placing the pulse oximeter sensor on the client's earlobe is not the standard practice for measuring the respiratory rate.
A nurse is assessing a client's respiratory rate and finds it to be 30 breaths per minute. What action should the nurse take?
Explanation
Answer: c. Assess the client for signs of respiratory distress.
Explanation: A respiratory rate of 30 breaths per minute is above the normal range (12-20 breaths per minute) and may indicate tachypnea or increased work of breathing. The nurse should assess the client for signs of respiratory distress and investigate the underlying cause.
a. Documenting the respiratory rate as normal would be inaccurate since it is above the normal range.
b. Initiating oxygen therapy is not the first-line intervention based solely on an increased respiratory rate but requires a comprehensive assessment of the client's respiratory status.
d. Administering a sedative medication is not appropriate solely based on an increased respiratory rate without further assessment.
A nurse is assessing a client's respiratory rate and finds it to be irregular, with periods of deep breaths alternating with shallow breaths. What action should the nurse take?
Explanation
Answer: d. Notify the healthcare provider of the irregular breathing pattern.
Explanation: An irregular breathing pattern with alternating periods of deep and shallow breaths may indicate a respiratory disorder or impairment. The nurse should notify the healthcare provider for further evaluation and intervention.
a. Documenting the irregular breathing pattern as a normal variation would be inappropriate since it may indicate an underlying respiratory issue.
b. Reassessing the respiratory rate after 30 minutes may delay appropriate intervention if there is an underlying respiratory problem.
c. Initiating oxygen therapy is not the first-line intervention based solely on an irregular breathing pattern but requires further assessment and evaluation.
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