A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

Stridor

Kussmaul respirations

Apneustic respirations

Cheyne-Stokes respirations

Answer and Explanation

The Correct Answer is D

Answer: D. Cheyne-Stokes respirations

Rationale:

A) Stridor: Stridor is a high-pitched, wheezing sound resulting from disrupted airflow in the upper airway. It is not characterized by alternating periods of hyperventilation and apnea, making this choice incorrect.

B) Kussmaul respirations: Kussmaul respirations are deep, labored breaths typically associated with metabolic acidosis, such as diabetic ketoacidosis. These respirations do not exhibit alternating periods of hyperventilation and apnea, so this option is not applicable.

C) Apneustic respirations: Apneustic respirations are characterized by prolonged inhalation followed by a prolonged pause before exhalation. This pattern does not align with the alternating hyperventilation and apnea described, making it an incorrect choice.

D) Cheyne-Stokes respirations: Cheyne-Stokes respirations are characterized by a cyclical pattern of increasing depth and rate of breathing followed by a gradual decrease in depth and a period of apnea. This description matches the client's breathing pattern of alternating hyperventilation and apnea, making this the correct answer.

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Free Nursing Study Resources

Correct Answer is ["2"]

Explanation

2 capsules

To calculate the number of capsules, use the formula:

capsules = (desired dose in mg / available dose in mg) x 1 capsule

Plug in the given values:

capsules = (300 mg / 150 mg) x 1 capsule

Simplify and solve:

capsules = 2 x 1 capsule

capsules = 2 capsules

Round to the nearest whole number and add a leading zero if needed:

capsules = 2 capsules

A. Patency of the intravenous line. B. Need for suctioning. C. Integrity of the dressing. D. Level of pain.

Correct Answer is B

Explanation

Suctioning is the priority observation in the client's care, as it prevents airway obstruction and respiratory distress caused by blood, mucus, or secretions. The client has a permanent tracheostomy and cannot cough

or clear the airway eﬀectively. The nurse should assess the need for suctioning frequently and perform it as needed, using sterile technique and maintaining oxygenation.

a) Patency of the intravenous line is important, but not the priority observation in the client's care. The intravenous line provides ﬂuids, electrolytes, and medications to the client, but it does not aﬀect the airway patency or oxygenation.
c) Integrity of the dressing is important, but not the priority observation in the client's care. The dressing protects the surgical site from infection and bleeding, but it does not aﬀect the airway patency or oxygenation.
d) Level of pain is important, but not the priority observation in the client's care. The pain can be managed with analgesics and nonpharmacological measures, but it does not aﬀect the airway patency or oxygenation.

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A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer lithium 300 mg PO every 8 hr. Available is lithium carbonate 150 mg capsules. How many capsules should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["2"]

Explanation

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Correct Answer is B

Explanation

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