A nurse is assessing an elderly patient receiving palliative care who exhibits Cheyne-Stokes respirations. Which of the following characteristics should the nurse identify as indicative of this respiratory pattern?
Rapid respirations that are unusually deep and regular.
An inability to breathe without dyspnea unless sitting upright.
Breathing ranging from very deep to very shallow with periods of apnea.
Shallow breathing alternating with periods of apnea.
The Correct Answer is C
Choice A rationale
Rapid respirations that are unusually deep and regular are not indicative of Cheyne-Stokes respirations. Cheyne-Stokes respirations are characterized by periods of apnea followed by gradually increasing then decreasing tidal volumes until another period of apnea.
Choice B rationale
An inability to breathe without dyspnea unless sitting upright is not indicative of Cheyne- Stokes respirations. This is more characteristic of orthopnea, which is commonly seen in conditions like heart failure.
Choice C rationale
Breathing ranging from very deep to very shallow with periods of apnea is indicative of Cheyne-Stokes respirations. This pattern of breathing is often seen in conditions such as heart failure, stroke, or brain damage.
Choice D rationale
Shallow breathing alternating with periods of apnea is not indicative of Cheyne-Stokes respirations. In Cheyne-Stokes respirations, the pattern of breathing includes periods of apnea followed by a gradual increase and then decrease in the depth of respirations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Assisting the guest to the floor and beginning mouth-to-mouth resuscitation is not the appropriate initial response. The guest’s symptoms indicate choking, and the Heimlich maneuver is the recommended first aid response.
Choice B rationale
The Heimlich maneuver is the correct response when someone is choking. The guest’s symptoms of a weak cough, inability to speak, and grasping the throat are classic signs of choking.
Choice C rationale
Observing the guest before taking further action is not appropriate in this situation. Immediate action is required to clear the guest’s airway.
Choice D rationale
Slapping the guest on the back is not the recommended response for choking in adults. It can potentially cause the object to become more deeply lodged in the throat.
Correct Answer is A
Explanation
The correct answer is Choice A. The client is receiving an oxygen concentration of 28%. Nasal cannulas can deliver oxygen at a flow rate ranging from 1 to 6 liters per minute (L/min), with
each additional liter increasing the fraction of inspired oxygen (FiO2) by 4%. Therefore, at 2 L/min, the client is receiving an oxygen concentration of 28%78.
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