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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
To calculate the amount of mL to administer, the nurse should use the following formula:
(mg ordered / mg available) x mL available = mL to administer
Substituting the values from the question, the nurse should do the following:
(100 mg / 250 mg) x 2 mL = 0.8 mL
Correct Answer is C
Explanation
Intercostal retractions, or the inward movement of the chest wall between the ribs, are a sign of respiratory distress and hypoxia. They indicate increased work of breathing and reduced lung expansion, which are common in clients who have postoperative atelectasis. Atelectasis is a collapse of alveoli in a part of the lung, which impairs gas exchange and oxygenation.
a) Lethargy, or a state of reduced mental alertness and energy, is not a typical manifestation of hypoxia. It can be caused by other factors, such as pain, medication, infection, or electrolyte imbalance. Hypoxia usually causes restlessness, anxiety, or confusion.
b) Bradycardia, or a slow heart rate, is not a typical manifestation of hypoxia. It can be caused by other factors, such as medication, vagal stimulation, or heart block. Hypoxia usually causes tachycardia, or a fast heart rate, as the body tries to compensate for the low oxygen level.
d) Bradypnea, or a slow respiratory rate, is not a typical manifestation of hypoxia. It can be caused by other factors, such as medication, brain injury, or metabolic alkalosis. Hypoxia usually causes tachypnea, or a fast respiratory rate, as the body tries to increase oxygen intake and carbon dioxide elimination.
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