A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:

respirations gradually decreasing in rate and depth.

rapid wheezing respirations for two or three breaths with short periods of apnea.

a breathing pattern of dyspnea followed by a short period of apnea.

quick shallow respirations with long periods of apnea.

Answer and Explanation

The Correct Answer is C

A.   Gradual decreases in rate and depth are typically seen in other respiratory conditions, not Cheyne- Stokes breathing.
B.   Wheezing is not associated with Cheyne-Stokes breathing but may be related to airway obstructions or lung conditions.
C.   Cheyne-Stokes breathing is characterized by a pattern of deep, rapid breathing followed by a period of apnea, commonly seen in terminally ill patients.
D.   Quick shallow respirations with long periods of apnea are not characteristic of Cheyne-Stokes breathing.

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Correct Answer is C

Explanation

A. Wrapping the cuff snugly around the arm is important for an accurate reading. The cuff should be snug but not tight to avoid false readings.
B. Positioning the cuff bladder over the brachial artery ensures the correct placement for accurate measurement.
C. Placing the arm above the level of the heart can lead to a falsely low blood pressure reading. The arm should be at heart level for an accurate measurement.
D. Ensuring the gauge starts at zero is critical for accurate measurement and avoids errors in reading.

A. pump up the cuff until no sound is heard and then let the air out. B. stop midway and begin to inflate again. C. make sure the bell of the stethoscope is placed firmly over the artery. D. continue to listen until the cuff is deflated.

Correct Answer is D

Explanation

Rationale
A. Pumping the cuff until no sound is heard may cause inaccurate readings and is not a proper technique.
B. Stopping midway can result in missing sounds or causing an inaccurate measurement.

C. The bell of the stethoscope should be used for low-pitched sounds, but the key is to continue listening to identify the full Korotkoff sound range, especially in the presence of an auscultatory gap.
D. It is important to continue listening until the cuff is deflated to ensure the accurate measurement of both systolic and diastolic pressures, particularly in patients with an auscultatory gap.

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A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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