Question

When the nurse enters the room to measure vital signs in preparing the client for a diagnostic test, the client is on the phone. What technique should the nurse use to determine the respiratory rate?

1) Count the respirations during conversational pauses.
2) Ask the client to end the phone call now and resume it at a later time
3) Wait at the client's bedside until the phone call is completed and then count respirations
4) Since there is no evidence of distress or urgency, defer the measurement.

Answer 1

Counting the client's respirations during conversational pauses is the suitable method for a nurse to determine the respiratory rate when the client is on the phone. This technique is discreet and maintains the accuracy of the assessment.

Step-by-step explanation:

When a nurse enters a room to measure vital signs and the client is busy on the phone, the most appropriate technique to determine the respiratory rate is to count the respirations during conversational pauses (option 1). This allows the nurse to assess the respiratory rate without disturbing the client and maintains accuracy, as the client may alter their breathing if they know they are being observed. It's important to remember that the respiratory rate is an essential vital sign that reflects the patient's health status. The medulla oblongata regulates breathing based on carbon dioxide, oxygen, and pH levels in the blood, and any changes in respiratory rate could indicate an underlying condition.