A critically ill patient has faster and deeper, then slower, respirations. These are followed by a period of no breathing for 21 seconds with continuation of this cycle. This respiratory pattern is

Kussmaul's respirations.

Cheyne-Stokes respirations.

Biot's respirations.

Hyperventilation.

Answer and Explanation

The Correct Answer is B

A.   Kussmaul's respirations are rapid, deep, and labored breaths often seen in metabolic acidosis, which does not match the pattern described.
B.   Cheyne-Stokes respirations are characterized by a pattern of deep and fast breathing followed by periods of apnea. This pattern is seen in patients with severe conditions like heart failure or brain injury.
C.   Biot's respirations are irregular, but the cycle does not have a distinct pattern of fast, slow, and apnea periods.
D.   Hyperventilation refers to an increased rate of breathing but does not involve the cycles of deep, slow, and apneic phases characteristic of Cheyne-Stokes.

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Correct Answer is C

Explanation

A. The area directly below the sternum is not the location for the apical pulse.
B. The third intercostal space is too high for the apical pulse, which is best heard at the fifth intercostal space.
C. The left midclavicular line at the fifth intercostal space is the proper location for auscultating the apical pulse.
D. Placing the stethoscope above the left nipple does not ensure accurate assessment of the apical pulse.

A. "You stand 20 feet away from the chart while I test each of your eyes." B. The number beside the largest print read is your visual acuity score! C. "I will be testing your vision with your reading glasses on." D. "You stand 50 feet away from the chart while I test each of your eyes."

Correct Answer is A

Explanation

A. The patient should stand 20 feet away from the Snellen chart to accurately measure visual acuity, which is the standard procedure.

B. The number beside the largest print is not the correct visual acuity score; the patient must read progressively smaller lines.
C. Testing with reading glasses is appropriate only for patients who need them for close-up vision, but the Snellen test typically measures distance vision.
D. The distance should be 20 feet, not 50 feet, to ensure proper testing conditions.

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A critically ill patient has faster and deeper, then slower, respirations. These are followed by a period of no breathing for 21 seconds with continuation of this cycle. This respiratory pattern is

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse taking an apical pulse would place the stethoscope at:

Correct Answer is C

Explanation

The nurse tells a patient that he will be performing a visual acuity test using the Snellen eye chart. The patient asks how the test is done. The nurse's best reply is:

Correct Answer is A

Explanation

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