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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Correct Answer is C

Explanation

Heparin is an anticoagulant that prevents the formation of new clots and the extension of existing clots. It is the drug of choice for treating acute pulmonary embolism, which is a life-threatening condition caused by a blood clot that travels to the lungs and blocks a pulmonary artery.

a) Dexamethasone is a corticosteroid that reduces inﬂammation and suppresses immune response. It is not indicated for treating pulmonary embolism, but it may be used for other pulmonary conditions, such as asthma or COPD.
b) Atropine is an anticholinergic that blocks the action of acetylcholine and increases heart rate and cardiac output. It is not indicated for treating pulmonary embolism, but it may be used for bradycardia or asystole.
d) Furosemide is a loop diuretic that increases urine output and reduces ﬂuid volume and blood pressure. It is not indicated for treating pulmonary embolism, but it may be used for heart failure or edema.

A. A client who has had radiation therapy for head and neck cancer B. A client who has had prolonged diarrhea C. A client who has had a cerebrovascular accident D. A client who has lactose intolerance E. A client who is 4 hr postoperative following a leg amputation with general anesthesia

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

Explanation

These clients have impaired swallowing, gag reﬂex, or level of consciousness, which increase their risk of aspiration while eating.

The other options are not correct because:

b. A client who has had prolonged diarrhea does not have a direct risk factor for aspiration, as diarrhea aﬀects the lower gastrointestinal tract and not the upper airway or esophagus.

d. A client who has lactose intolerance does not have a risk factor for aspiration, as lactose intolerance causes abdominal cramps, bloating, gas, or diarrhea when consuming dairy products, but does not aﬀect the ability to swallow or protect the airway.

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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 caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

Correct Answer is C

Explanation

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk of aspiration while eating? (Select all that apply)

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

Explanation

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