Conclusion
Conclusion ( 9 Questions)
A nurse is assessing a client's respiratory rate and finds it to be 8 breaths per minute. What action should the nurse take first?
The oral route is commonly used and provides a convenient method for temperature measurement but may not be as accurate as the rectal route.
The axillary route is less invasive but tends to be less accurate than the rectal route.
The tympanic route provides a quick measurement but may not be as accurate as the rectal route, especially in young children
Rectal Explanation: The rectal route is considered the most accurate method for obtaining core body temperature because it reflects the temperature of the blood perfusing the hypothalamus.
Explanation: A respiratory rate of 8 breaths per minute is significantly below the normal range (12-20 breaths per minute), indicating potential respiratory distress. The nurse should perform a thorough respiratory assessment to gather more information and determine appropriate interventions.
a. Administering oxygen may be necessary, but the nurse should first assess the client's respiratory status before initiating any interventions.
b. Placing the client in a supine position is not indicated and may worsen respiratory distress in some situations.
c. Reassessing after 1 hour is not appropriate when a client is experiencing abnormal vital signs; immediate action is needed.