A nurse cares for a hospice client who exhibits irregular breathing patterns, alternating between periods of apnea and hyperventilation. What breathing pattern should the nurse document?

Kussmaul respirations

Cheyne-Stokes respirations

Agonal breathing

Biot's respirations

Answer and Explanation

The Correct Answer is B

A. Kussmaul respirations: These are deep, rapid, and labored respirations typically associated with metabolic acidosis, such as diabetic ketoacidosis. They do not include alternating periods of apnea and hyperventilation, so they do not match the described pattern.

B. Cheyne-Stokes respirations: This breathing pattern is characterized by cyclic periods of increasing and decreasing depth of respiration, followed by temporary apnea. It commonly occurs in clients with advanced heart failure, neurological injury, or nearing end-of-life, making it consistent with hospice clients exhibiting irregular breathing.

C. Agonal breathing: Agonal respirations are irregular, gasping breaths often seen in severe hypoxia or near death. They are typically ineffective for gas exchange and not part of a regular cyclical pattern.

D. Biot's respirations: Biot’s respirations consist of groups of quick, shallow breaths followed by irregular pauses. They are usually associated with increased intracranial pressure or medullary damage rather than end-of-life breathing patterns.

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Correct Answer is ["B","C","E"]

Explanation

A. Blood pressure: The client’s blood pressure is 120/82 mm Hg, which is within normal limits for a 68-year-old adult and does not require immediate follow-up.

B. Respiration rate: A respiratory rate of 26 breaths per minute is elevated (normal 12–20) and may indicate pain, anxiety, or early respiratory compromise. Further assessment is needed to determine the cause and prevent complications such as hypoxia or pulmonary embolism.

C. Lack of ambulation: The client has not been out of bed since surgery, despite orders to ambulate three times daily. Immobility increases the risk of complications such as deep vein thrombosis, pulmonary embolism, and delayed functional recovery, requiring prompt intervention.

D. Body mass index: A BMI of 26.6 indicates overweight but is not an acute concern requiring immediate follow-up in the postoperative setting.

E. Oxygen saturation: An oxygen saturation of 88% on room air is below the expected range (≥92%) and signals hypoxemia. Immediate follow-up is necessary to assess respiratory status, provide supplemental oxygen, and prevent respiratory complications.

A. Assess extremity circulation distal to the restraints. B. Remove the restraints when they are no longer needed. C. Ask the client if they want the restraints removed. D. Replace the restraints with new ones when soiled or wet. E. Remove the restraints every four hours for five minutes

Correct Answer is ["A","B","D"]

Explanation

A. Assess extremity circulation distal to the restraints: Continuous monitoring of circulation, sensation, and movement below the restraints is essential to prevent tissue ischemia, nerve injury, and pressure injuries. Early detection of compromised circulation allows timely intervention and restraint adjustment.

B. Remove the restraints when they are no longer needed: Restraints should be used for the shortest duration necessary to ensure client safety. Removing them promptly when no longer required reduces the risk of physical and psychological complications, including skin breakdown and agitation.

C. Ask the client if they want the restraints removed: Clients who are intubated or otherwise unable to safely remove restraints may lack the capacity to make this decision. Safety overrides preference in acute situations, and reliance on client request alone is insufficient.

D. Replace the restraints with new ones when soiled or wet: Wet or soiled restraints increase the risk of skin breakdown, infection, and discomfort. Routine replacement ensures hygiene and maintains safe, effective restraint application.

E. Remove the restraints every four hours for five minutes: Current standards recommend more frequent assessment and removal based on institutional policy, client condition, and regulatory guidelines. Typically, restraints are removed and range-of-motion exercises performed every 2 hours, not every 4 hours.

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A nurse cares for a hospice client who exhibits irregular breathing patterns, alternating between periods of apnea and hyperventilation. What breathing pattern should the nurse document?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C","E"]

Explanation

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Correct Answer is ["A","B","D"]

Explanation

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