to accurately assess a patients respiration rate which of the following methods would be best

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. To accurately assess a patient's respiration rate, which of the following methods would be BEST?

A. Tell the patient, 'Please remain silent while I count your number of breaths.'
B. Count respirations at the same time you are counting the pulse rate
C. Count the pulse rate for one minute, then, while keeping your index fingers on the patient's radial artery, count the respirations for an additional minute.
D. Count the patient's respiration rate, then take the patient's temperature, and then take the pulse rate.

Correct answer: B

Rationale: The most accurate method to assess a patient's respiration rate is to count the breaths simultaneously while counting the pulse rate. This approach ensures that the patient is unaware of the specific focus on their breathing, preventing any conscious alteration in breathing patterns. Choice A is incorrect because informing the patient may lead to altered breathing as the patient may consciously change their breathing pattern. Choice C involves counting the pulse rate first, which is not necessary for assessing respiration rate. Choice D is incorrect as it includes unnecessary steps such as taking the patient's temperature before counting respiration rate, which adds no value to accurately assessing the respiration rate.

2. Which technique is correct when assessing the radial pulse of a patient?

A. Palpate for 1 minute if the rhythm is irregular.
B. Palpate for 15 seconds and multiply by 4 if the rhythm is regular.
C. Palpate for 2 full minutes to detect any variation in amplitude.
D. Palpate for 10 seconds and multiply by 6 if the rhythm is regular and the patient has no history of cardiac abnormalities.

Correct answer: A

Rationale: When assessing the radial pulse, if the rhythm is irregular, the pulse should be counted for a full minute to get an accurate representation of the pulse rate. In cases where the rhythm is regular, the recommended technique is to palpate for 15 seconds and then multiply by 4 to calculate the beats per minute. This method is more accurate and efficient for normal or rapid heart rates. Palpating for 30 seconds and multiplying by 2 is not as effective, as any error in counting results in a larger discrepancy in the calculated heart rate. Palpating for 2 full minutes is excessive and not necessary for routine pulse assessment. Palpating for 10 seconds and multiplying by 6 is not a standard technique and may lead to inaccuracies, especially in patients with cardiac abnormalities.

3. Patients have a right to ______________.

A. only enough information so they can comply with care
B. ALL of their health-related information
C. small amounts of information so they do not get nervous
D. moderate amounts of information unless they are old

Correct answer: B

Rationale: Patients have a legal right to access all of their health-related information. This includes details about their health condition, treatment options, test results, and any other relevant data. Providing patients with all their health-related information empowers them to make informed decisions about their care, promotes transparency in the healthcare process, and respects their autonomy. Choices A, C, and D are incorrect because they restrict the information patients should receive based on assumptions or limitations, which goes against the principle of patient autonomy and their right to access their complete health-related information.

4. When assessing the force or strength of a pulse, what would the nurse recall about the pulse?

A. Is a reflection of the heart's stroke volume
B. Typically recorded on a 0- to 3-point scale
C. Demonstrates elasticity of the blood vessel wall
D. Reflects the blood volume in the arteries during diastole

Correct answer: A

Rationale: When assessing the force or strength of a pulse, the nurse should recall that it is a reflection of the heart's stroke volume. The heart pumps an amount of blood (the stroke volume) into the aorta, causing arterial walls to flare and generate a pressure wave felt as the pulse in the periphery. The force of the pulse is typically recorded on a 0- to 3-point scale, not a 0- to 2-point scale. The force of the pulse does not demonstrate the elasticity of blood vessel walls or reflect the blood volume in the arteries during diastole. Therefore, choices B, C, and D are incorrect.

5. A healthcare professional is preparing to administer a dose of platelets to a client. Which of the following actions must the healthcare professional perform before giving the platelets?

A. Start an IV of 0.9% Normal Saline to administer with the platelets
B. Ensure the container with the platelets is intact and not damaged
C. Verify the client's identity using two unique identifiers
D. Check the client's chart to ensure no contraindications to platelet transfusion

Correct answer: B

Rationale: Before administering platelets, it is crucial to check the integrity of the container holding the blood product. An intact container ensures the sterility and safety of the platelets, minimizing the risk of contamination or infection. Option A is incorrect as administering platelets typically does not require starting a new IV line unless indicated for the specific patient. Option C is not the priority as verifying the client's identity can be done at any point during the administration process but is not specific to the platelet transfusion itself. Option D, checking the client's chart for antibiotic use, is not directly related to ensuring the safety of the blood product container.