A nurse is assessing an elderly patient receiving palliative care who exhibits Cheyne-Stokes respirations. Which of the following characteristics should the nurse identify as indicative of this respiratory pattern?
Rapid respirations that are unusually deep and regular.
An inability to breathe without dyspnea unless sitting upright.
Breathing ranging from very deep to very shallow with periods of apnea.
Shallow breathing alternating with periods of apnea.
The Correct Answer is C
Choice A rationale
Rapid respirations that are unusually deep and regular are not indicative of Cheyne-Stokes respirations. Cheyne-Stokes respirations are characterized by periods of apnea followed by gradually increasing then decreasing tidal volumes until another period of apnea.
Choice B rationale
An inability to breathe without dyspnea unless sitting upright is not indicative of Cheyne- Stokes respirations. This is more characteristic of orthopnea, which is commonly seen in conditions like heart failure.
Choice C rationale
Breathing ranging from very deep to very shallow with periods of apnea is indicative of Cheyne-Stokes respirations. This pattern of breathing is often seen in conditions such as heart failure, stroke, or brain damage.
Choice D rationale
Shallow breathing alternating with periods of apnea is not indicative of Cheyne-Stokes respirations. In Cheyne-Stokes respirations, the pattern of breathing includes periods of apnea followed by a gradual increase and then decrease in the depth of respirations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Applying the pulse oximeter probe to the toe might not provide an accurate reading if the client has poor peripheral circulation. Additionally, thickened toenails can interfere with the reading.
Choice B rationale
Edema in the hands can affect the accuracy of a pulse oximeter reading. The probe might not fit properly or provide a reliable reading if the finger is swollen.
Choice C rationale
Applying the pulse oximeter probe to a skin fold is not recommended. The probe needs to be placed on a relatively flat, thin area of skin to accurately measure oxygen saturation.
Choice D rationale
The earlobe is a suitable alternative site for pulse oximetry if the fingers and toes are not viable options. The earlobe is typically less affected by peripheral vasoconstriction, which can occur with hypothermia, certain medications, and certain diseases. Therefore, Choice D is the correct answer.
Correct Answer is C
Explanation
Step 1 is to determine how many mL to administer. The client needs 300 mg of amoxicillin and the available medication is 250 mg/5 mL. So, the calculation is (300 mg ÷ 250 mg/mL) × 5 mL.
Step 2 is to perform the calculation. The result is 6 mL.
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