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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale
While antibiotics are used to treat bacterial infections, crackles in the lungs can be a sign of various conditions, not just bacterial infections. Therefore, administering antibiotics is not the appropriate action based solely on the finding of crackles.
Choice B rationale

Limiting fluid intake can be beneficial for clients with certain conditions such as heart failure, but it is not the appropriate action based solely on the finding of crackles.
Choice C rationale
Initiating bedrest in semi-Fowler’s position can help improve lung expansion and ease breathing in clients with certain respiratory conditions. However, it is not the appropriate action based solely on the finding of crackles.
Choice D rationale
Crackles can sometimes be cleared by deep breathing and coughing. Repeating the auscultation after asking the client to breathe deeply and cough can help the nurse determine if the crackles are transient (cleared by coughing) or persistent.

A. Turn the torso at the waist when reaching for objects. B. Use ice packs intermittently for 48 hours. C. Use 10 lb arm weights to start strengthening the back muscles. D. Stay in bed except for toileting during the first 24 hours.

Correct Answer is B

Explanation

Choice A rationale
Turning the torso at the waist when reaching for objects can actually increase the risk of back injury. It’s important to keep the back straight and bend at the knees when lifting or reaching for objects.
Choice B rationale

Using ice packs intermittently for 48 hours is a common recommendation for acute lower back pain. Ice can help reduce inflammation and numb the area, providing relief. It’s important to use the ice packs intermittently, not continuously, to avoid frostbite.
Choice C rationale
Using 10 lb arm weights to start strengthening the back muscles is not recommended for someone with acute lower back pain. Heavy lifting can exacerbate the pain and potentially cause further injury. It’s better to start with gentle, low-impact exercises and gradually increase intensity as the back heals.
Choice D rationale
Staying in bed except for toileting during the first 24 hours is not typically recommended for acute lower back pain. While rest is important, prolonged bed rest can actually lead to muscle stiffness and increased pain. It’s generally recommended to stay as active as possible without exacerbating the pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Upon auscultating a client’s lungs, the nurse identifies crackles in the left posterior base. What action should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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