A nurse caring for a patient on bed rest with a history of respiratory health problems should:

auscultate for bowel sounds once a shift.

auscultate lung sounds at the beginning of a shift.

monitor for skin turgor every shift.

monitor peripheral pulses once a shift.

Answer and Explanation

The Correct Answer is B

A.   Auscultating for bowel sounds once a shift is important but does not directly relate to the respiratory condition.
B.   Auscultating lung sounds at the beginning of a shift is a priority to assess for any signs of respiratory compromise or complications.
C.   Monitoring skin turgor every shift is important for hydration status but is less critical in comparison to lung sounds for a patient with respiratory problems.
D.   Monitoring peripheral pulses once a shift is important but does not address the respiratory condition directly.

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Correct Answer is C

Explanation

A. Gradual decreases in rate and depth are typically seen in other respiratory conditions, not Cheyne- Stokes breathing.
B. Wheezing is not associated with Cheyne-Stokes breathing but may be related to airway obstructions or lung conditions.
C. Cheyne-Stokes breathing is characterized by a pattern of deep, rapid breathing followed by a period of apnea, commonly seen in terminally ill patients.
D. Quick shallow respirations with long periods of apnea are not characteristic of Cheyne-Stokes breathing.

A. pump up the cuff until no sound is heard and then let the air out. B. stop midway and begin to inflate again. C. make sure the bell of the stethoscope is placed firmly over the artery. D. continue to listen until the cuff is deflated.

Correct Answer is D

Explanation

Rationale
A. Pumping the cuff until no sound is heard may cause inaccurate readings and is not a proper technique.
B. Stopping midway can result in missing sounds or causing an inaccurate measurement.

C. The bell of the stethoscope should be used for low-pitched sounds, but the key is to continue listening to identify the full Korotkoff sound range, especially in the presence of an auscultatory gap.
D. It is important to continue listening until the cuff is deflated to ensure the accurate measurement of both systolic and diastolic pressures, particularly in patients with an auscultatory gap.

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A nurse caring for a patient on bed rest with a history of respiratory health problems should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:

Correct Answer is C

Explanation

Older adult patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to:

Correct Answer is D

Explanation

The nurse covers a newborn baby's head with a cap. because the head:

The normal pattern of breathing is described as

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When educating a patient about the warning signs of cancer, the nurse includes which of the following? (Select all that apply.)