Elsevier Case studies Latest Version Already Graded A

Elsevier Case studies Latest Version Already Graded A Meet the Client: James Harrison James Harrison, a 9-yr old male, is brought to the Emergency Department (ED) by his mother because he is short of breath and unable to sleep, due to coughing. The 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? A. Place a hand on James' upper abdomen and observe the rise and fall of the chest. B. Encourage James to breathe as deeply and slowly as possible. C. Watch for nasal flaring and count the air exchanges with each movement. D. Observe chest expansion for 15 seconds and multiply by 4. A. Place a hand on James' upper abdomen and observe the rise and fall of the chest. This technique allows the nurse to observe and count each ventilatory cycle, even when respirations are shallow. James' respiratory rate is 36 breaths/min How should the nurse describe James' respiratory pattern? A. Eupnea B. Bradypnea C. Orthopnea D. Tachypnea D. Tachypnea A rapid respiratory rate, which is consistent with James's rate of 36 breaths/min. Normal respiratory rate for a school-aged child is 16-30 breaths/min. 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? A. Measure capillary refill B. Auscultate breath sounds C. Measure oxygen saturation D. Observe chest excursion C. Measure oxygen saturation. Oxygen saturation provides important data about the percentage of hemoglobin that is saturated with oxygen- a valuable reflection of the client's overall oxygenation. In assessing James' breath sounds, the nurse should ask him to perform which action? A. Breathe deeply through the mouth. B. Observe the color of the nailbeds and lips. C. Cough deeply after each breath. D. Hold his breath for fifteen seconds. A. Breathe deeply through the mouth. James should be instructed to breathe slowly and dee