During a respiratory assessment, the nurse is determining respirations per minute. Which factor(s) generally affect the character of respirations? Select all that apply.

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Question 1 of 5

During a respiratory assessment, the nurse is determining respirations per minute. Which factor(s) generally affect the character of respirations? Select all that apply.

Correct Answer: D

Rationale: The correct answer is D. Anxiety and exercise can significantly alter the character of respirations, increasing the rate and depth. Smoking primarily affects the health of the respiratory system in the long term but may not immediately impact the character of respirations. Therefore, choice C is incorrect. Choices A and B are correct as anxiety and exercise can lead to changes in the rate and depth of respirations.

Question 2 of 5

For which client situation would a consultation with a rapid response team (RRT) be most appropriate?

Correct Answer: A

Rationale: The correct answer is A. This client situation presents with concerning clinical signs such as no urine output post kidney transplant, elevated temperature, tachycardia, hypotension, and restlessness, suggestive of acute renal failure and sepsis. These signs necessitate immediate intervention by the rapid response team (RRT) to address the potentially life-threatening conditions. Choice B is incorrect as the client is stable after chest tube removal and primarily anxious about going home. Choice C is incorrect as the client's symptoms are related to postoperative recovery and boredom, not indicating an urgent need for RRT consultation. Choice D is incorrect as the client post hip repair is stable, alert, and interacting normally, without signs of acute deterioration requiring RRT involvement.

Question 3 of 5

A 31-year-old client is seeking contraceptive information. Before responding to the client's questions about contraceptives, the nurse obtains a health history. What factor in the client's history indicates to the nurse that oral contraceptives are contraindicated?

Correct Answer: C

Rationale: The correct answer is C. Smoking, especially in clients over 30, increases the risk of thromboembolic events, making oral contraceptives contraindicated. Choice A is incorrect as age alone is not a contraindication for oral contraceptives. Choice B is incorrect as having multiple pregnancies is not a contraindication for oral contraceptives. Choice D is incorrect as borderline hypertension is not a strict contraindication for oral contraceptives.

Question 4 of 5

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?

Correct Answer: B

Rationale: Weighing the client daily at the same time each day is the most accurate method for monitoring fluid balance. Changes in body weight can reflect fluid retention or loss. Measuring and recording fluid intake and output (Choice A) is important but may not provide immediate changes in fluid status. Assessing vital signs (Choice C) can offer some information but may not be as specific to fluid status as daily weighing. Checking the client's lungs for crackles (Choice D) is more related to assessing respiratory status rather than direct fluid monitoring.

Question 5 of 5

The nurse is told in report that the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?

Correct Answer: A

Rationale: The correct anatomical position for auscultating the murmur of aortic stenosis is the second intercostal space, right sternal border. This is where the aortic valve is best auscultated, and the murmur of aortic stenosis is heard most clearly. Choices B, C, and D are incorrect as the murmur of aortic stenosis is best heard at the second intercostal space on the right side of the sternum.

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