A nurse is caring for a client who is dying and having Cheyne-Stokes respirations. Which of the following respiratory findings should the nurse expect?

Irregular respirations with frequent periods of apnea

Irregular respirations greater than 20/min

Regular, rapid, shallow respirations

Regular respirations fewer than 12/min

Answer and Explanation

The Correct Answer is A

Cheyne-Stokes respirations are an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes. This type of breathing may occur in people who are dying due to heart failure, stroke, brain injury or other causes. The nurse should expect to observe irregular respirations with frequent periods of apnea in the client who is dying and having Cheyne-Stokes respirations.

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Correct Answer is ["A","C","E"]

Explanation

Stop the transfusion, place the client in high-Fowlers position, and administer oxygen to the client. The rationale for these answers is that these actions are appropriate interventions for a client who is experiencing circulatory overload, which is a potential complication of blood transfusion characterized by fluid overload in the lungs and heart failure. Stopping the transfusion will prevent further fluid accumulation, placing the client in high-Fowlers position will facilitate breathing and reduce venous return, and administering oxygen will improve oxygenation and tissue perfusion.

A. Instruct the client to flex their arm with the hand open. B. Dangle the client's arm over the edge of the bed. C. Apply a cool compress to the vein for 10 min. D. Stroke the skin near the vein in an upward direction.

Correct Answer is B

Explanation

Dangling the client's arm over the edge of the bed helps dilate the vein by increasing venous pressure due to gravity. Flexing the arm with the hand open does not affect venous dilation and may cause muscle tension that can impede insertion. Applying a cool compress constricts rather than dilates the vein by causing vasoconstriction. Stroking the skin near the vein may irritate or damage the vein and does not promote dilation.

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A nurse is caring for a client who is dying and having Cheyne-Stokes respirations. Which of the following respiratory findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

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Correct Answer is B

Explanation

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