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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale
The prone position, which involves lying flat on the stomach, is not typically recommended for a child with respiratory failure due to pneumonia. While prone positioning can be beneficial in

certain cases of severe acute respiratory distress syndrome, it does not generally allow for maximal lung expansion.
Choice B rationale
The supine position, which involves lying flat on the back, is not typically recommended for a child with respiratory failure due to pneumonia. This position can make it more difficult for the lungs to expand fully, potentially worsening respiratory distress.
Choice C rationale
The side-lying position is not typically recommended for a child with respiratory failure due to pneumonia. While this position can be comfortable for resting, it does not generally allow for maximal lung expansion.
Choice D rationale
The upright position is typically recommended for a child with respiratory failure due to pneumonia. Sitting upright can help to maximize lung expansion and improve oxygenation.

A. Turn the patient on their side before starting oral care. B. Apply petroleum jelly to the patient’s lips after oral care. C. Use the thumb and index finger to keep the patient’s mouth open. D. Use a stiff toothbrush to clean the patient’s teeth.

Correct Answer is A

Explanation

Choice A rationale
Turning the patient on their side before starting oral care is a recommended practice when caring for an unresponsive patient. This position helps prevent aspiration, which can occur if the patient cannot swallow properly.
Choice B rationale
Applying petroleum jelly to the patient’s lips after oral care can help prevent dryness and cracking. However, it’s not the primary action the nurse should take when performing oral hygiene for an unresponsive patient.
Choice C rationale
Using the thumb and index finger to keep the patient’s mouth open is not recommended. It can cause discomfort and potential injury to the patient.
Choice D rationale
Using a stiff toothbrush to clean the patient’s teeth is not recommended. A soft toothbrush is usually used to clean the teeth of an unresponsive patient to prevent damage to the gums.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a school-age child with respiratory failure due to pneumonia. Which position should the nurse encourage to allow for maximal lung expansion?

Correct Answer is D

Explanation

A nurse in a long-term care facility is taking care of a patient who is unresponsive. What action should the nurse take when performing oral hygiene for the patient?

Correct Answer is A

Explanation

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