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 ["2 ."]
Explanation
Step 1: Identify the prescribed dose and the available dose. The prescribed dose is 500 mg and the available dose is 250 mg per tablet.
Step 2: Use the formula for calculating the number of tablets: (Prescribed dose ÷ Available dose) = Number of tablets.
Step 3: Substitute the values into the formula: (500 mg ÷ 250 mg/tablet) = 2 tablets. So, the nurse should administer 2 tablets.
Correct Answer is B
Explanation
Choice A rationale
While manifestations of hypoglycemia are important to monitor in clients receiving insulin or oral hypoglycemic agents, they are not typically a primary concern in clients receiving TPN. TPN solutions contain dextrose, which can actually lead to hyperglycemia if not properly managed.
Choice B rationale
Monitoring the IV insertion site is crucial in clients receiving TPN. Infections and complications can occur at the site of insertion, so regular assessment is necessary. Therefore, Choice B is the correct answer.
Choice C rationale
The client’s oral intake is not a primary concern when receiving TPN, as TPN provides complete nutrition intravenously.
Choice D rationale
The height of the IV pole does not need to be monitored in clients receiving TPN. The infusion pump controls the rate of the TPN infusion.
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