The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment, what finding would the nurse expect?
Regular deep respirations interspersed with periods of apnea
A pattern of crescendo-decrescendo respirations followed by a period of apnea
Patient breathing less than 10 breaths per minute
Patient breathing shallow and more than 24 breaths per minute
The Correct Answer is B
A. Regular deep respirations interspersed with periods of apnea:
This describes periodic breathing, which is different from Cheyne-Stokes respirations. Periodic breathing consists of regular cycles of deep respirations followed by periods of apnea.
B. A pattern of crescendo-decrescendo respirations followed by a period of apnea
Cheyne-Stokes respirations are characterized by a pattern of crescendo-decrescendo respirations, meaning that the depth and rate of breathing gradually increase and then decrease. This is followed by a period of apnea, during which there is a temporary cessation of breathing. The cycle then repeats.
C. Patient breathing less than 10 breaths per minute:
This describes bradypnea, which is an abnormally slow respiratory rate. Cheyne-Stokes respirations involve rhythmic, cyclical changes in respiratory rate and depth.
D. Patient breathing shallow and more than 24 breaths per minute:
This describes tachypnea, which is an abnormally fast respiratory rate. Cheyne-Stokes respirations are characterized by a distinct pattern of alternating crescendo-decrescendo respirations followed by apnea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["45"]
Explanation
To calculate the amount of potassium chloride (K-Dur) solution to administer, we need to use the following formula:
mL to administer = ordered dose (mEq) / available dose (mEq/mL) x mL
Plugging in the values from the question, we get:
mL to administer = 60 mEq / (20 mEq / 15 mL) x 15 mL
Simplifying the equation, we get:
mL to administer = 60 mEq x 15 mL / 20 mEq
mL to administer = 45 mL
Therefore, the nurse should administer 45 mL of potassium chloride (K-Dur) solution to the patient.
Correct Answer is C
Explanation
A. Assess the pedal pulses with a Doppler device:
Assessing the pedal pulses with a Doppler device may be useful in certain situations, but when the radial pulse is irregular, it's more important to assess the central (apical) pulse to get a more accurate representation of the heart's rhythm.
B. Assess the apical pulse with a Doppler device:
While using a Doppler device on the apical pulse is an option, it's generally not the first choice when assessing irregular pulses. The apical pulse can often be palpated manually, and it's more practical to assess it directly for irregularities.
C. Assess the apical pulse for a full minute:
This is the recommended action when the radial pulse is irregular. By assessing the apical pulse for a full minute, the nurse can accurately determine the heart rate and identify any irregularities in rhythm, providing a comprehensive assessment of the cardiac status.
D. Assess the pedal pulses for a full minute:
While assessing the pedal pulses is important in certain situations, it may not be the priority when dealing with an irregular radial pulse. Assessing the apical pulse for a full minute gives a more direct and accurate reflection of the heart's rhythm.
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