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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Free Nursing Study Resources

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

Explanation

A. A dressing helps protect the wound from contamination: Dressings act as a physical barrier against microorganisms, debris, and external trauma. Maintaining a protected environment reduces the risk of local infection and supports optimal healing conditions. This is a fundamental purpose of wound dressings.

B. The wound and the surrounding skin need to be cleaned with each dressing change: Cleansing removes exudate, necrotic debris, and surface bacteria that can delay healing. Cleaning the surrounding skin also prevents maceration and skin breakdown from drainage. Consistent cleansing supports accurate wound assessment.

C. A dressing is required for an open wound with extensive tissue loss: Open wounds with significant tissue loss require coverage to maintain moisture balance and protect exposed structures. Dressings support granulation tissue formation and reduce evaporative fluid loss. Leaving such wounds uncovered increases infection risk.

D. The dressing type should stay the same throughout the course of wound treatment: Dressing selection should change as the wound progresses through healing phases. Variations in exudate level, tissue type, and infection risk require different dressing properties. Ongoing reassessment guides appropriate modification.

E. The dressing should control drainage without fully drying out the wound bed: A moist wound environment promotes epithelialization and cellular migration. Dressings should absorb excess exudate while preventing desiccation of viable tissue. Proper moisture balance accelerates healing and reduces pain.

A. “I will use the cane to support all of my weight when walking." B. "I will make sure my elbow is bent slightly when I hold the cane." C. "I will move the strong leg up the stairs first, then the cane, and then the weak leg." D. “I will hold the cane on the weak side of my body to support it."

Correct Answer is B

Explanation

A. “I will use the cane to support all of my weight when walking.": A cane is meant to provide partial support and improve balance, not bear the client’s full weight. Relying entirely on the cane can cause instability and increase the risk of falls.

B. "I will make sure my elbow is bent slightly when I hold the cane.": Proper cane use requires a slight elbow flexion of about 20–30 degrees. This position ensures optimal support, reduces strain on the shoulder and wrist, and promotes safe ambulation.

C. "I will move the strong leg up the stairs first, then the cane, and then the weak leg.": When using a cane, it should move simultaneously with the weaker leg while ascending or descending stairs to provide support. Moving the strong leg first without coordinating the cane can compromise safety.

D. “I will hold the cane on the weak side of my body to support it.": The cane should be held on the strong side to provide counterbalance and allow the weaker leg to bear weight safely. Holding it on the weak side decreases stability and increases fall risk.

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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

Which statement(s) are true when selecting and applying a dressing for a client with a wound? Select all that apply.

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

Explanation

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Correct Answer is B

Explanation

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