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
Cheyne-Stokes respirations are a cyclic pattern of breathing that consists of gradually increasing and decreasing tidal volumes, followed by a period of apnea. They are often seen in clients who have brain damage, heart failure, or drug overdose.
- Stridor is a high-pitched, inspiratory sound that indicates upper airway obstruction. It is not a pattern of breathing, but a sign of respiratory distress.
- Kussmaul respirations are rapid, deep, and labored breaths that indicate metabolic acidosis. They are not characterized by periods of apnea, but by a constant increase in ventilation.
- Apneustic respirations are prolonged, gasping inspirations followed by short, ineffective expirations. They indicate damage to the pons or lower brainstem. They are not characterized by periods of hyperventilation, but by a lack of normal respiratory rhythm.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D"]
Explanation
Clubbing of the fingers is a sign of chronic hypoxia, which occurs in emphysema due to impaired gas exchange and reduced oxygen delivery to the tissues.
The other options are not correct because:
- Dyspnea is a common symptom of emphysema, but it is not a specific finding that indicates the presence of the condition.
- Barrel chest is a result of hyperinflation of the lungs, which can occur in emphysema, but it can also be seen in other respiratory disorders such as asthma or cystic fibrosis.
- Deep respirations are not typical of emphysema, as the client tends to breathe shallowly and rapidly to minimize the work of breathing.
- Bradycardia is not associated with emphysema, as the client usually has tachycardia due to increased sympathetic stimulation and reduced cardiac output.
Correct Answer is D
Explanation
Keeping the drainage system below the level of the client's chest prevents backflow of fluid or air into the pleural space and maintains negative pressure in the system.
a) Disconnecting the chest tube from the drainage system during transport is dangerous and can cause pneumothorax, infection, or bleeding. The chest tube should remain connected to the drainage system at all times unless ordered by the provider.
b) Emptying the collection chamber prior to transport is unnecessary and can interfere with accurate measurement of drainage. The collection chamber should be emptied only when it is full or at the end of each shift.
c) Clamping the chest tube prior to transferring the client to a wheelchair is contraindicated and can cause tension pneumothorax, as it prevents air from escaping the pleural space. The chest tube should only be clamped for a brief period when changing the drainage system or checking for air leaks, and only with a provider's order.
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