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 ["0.7"]
Explanation
To calculate the amount of hydroxyzine (Vistaril) to administer, use the formula:
D (desired dose) / H (have dose) x Q (quantity) = X (amount to give)
In this case, D = 35 mg, H = 50 mg/mL, and Q = 1 mL. Plug in the values and solve for X:
35 mg / 50 mg/mL x 1 mL = 0.7 mL
Therefore, the amount of hydroxyzine (Vistaril) to administer is 0.7 mL.
Correct Answer is C
Explanation
Correct Answer: C
C. The provider was notified.The nurse should document objective facts, such as notifying the provider, in the client’s medical record. This ensures accurate communication about the client's condition and the steps taken after the fall.
Incorrect answers:
A."An incident report was completed."The completion of an incident report should not be documented in the medical record. Incident reports are internal documents used for quality improvement and risk management, and mentioning them in the medical record could make them discoverable in legal proceedings.
B."There were no injuries sustained."While documenting the client’s physical condition is appropriate, stating "no injuries sustained" might be premature or subjective. Instead, the nurse should record specific observations, such as "client denies pain" or "no visible signs of injury noted."
D."An incident report was forwarded to risk management.Referencing the incident report in the medical record is inappropriate. Incident reports are separate from the client’s medical record and should not be mentioned in the documentation.
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