Questions And Answers
\.Assessment SkillsThe nurse assesses James' vital signs. His respirations are rapid and shallow.
Which is the best technique for the nurse to use to assess James' respirations accurately? -
Answer- Place a hand on James' upper abdomen and observe the rise and fall of the chest.
\.James' respiratory rate is 36 breaths/min. How should the nurse describe James' respiratory
pattern? - Answer- Tachypnea
\.Because of James' dyspnea, the nurse is concerned that he may need to receive oxygen. To
determine the need for supplemental oxygen, which assessment is most important for the
nurse to perform? - Answer- Measure oxygen saturation.
\.In assessing James' breath sounds, the nurse should ask him to perform which action? -
Answer- Breathe deeply through the mouth.
\.To measure capillary refill, the nurse must first perform which action? - Answer- Compress
the nailbed of one finger until it blanches.
\.James' mother states that this is the third time in recent months she has brought him to the
ED with a cough and shortness of breath. The nurse asks the mother how many respiratory or
other infections James has had within the past year. Why does the nurse ask this? - Answer-
To assess for a possible immune deficiency disorder.
\.Which response is best for the nurse to provide? - Answer- "The clip feels like squeezing
your finger with your other hand."