A nurse is caring for a client who is dying and having Cheyne-Stokes respirations. Which of the following respiratory findings should the nurse expect?

Irregular respirations with frequent periods of apnea

Irregular respirations greater than 20/min

Regular, rapid, shallow respirations

Regular respirations fewer than 12/min

Answer and Explanation

The Correct Answer is A

Cheyne-Stokes respirations are an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes. This type of breathing may occur in people who are dying due to heart failure, stroke, brain injury or other causes. The nurse should expect to observe irregular respirations with frequent periods of apnea in the client who is dying and having Cheyne-Stokes respirations.

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Correct Answer is A

Explanation

False imprisonment. The rationale for this answer is that false imprisonment is the unlawful confinement of a person without consent or legal justification. The nurse violated the client's right to freedom of movement by placing him in restraints without a valid prescription or indication.

A. Bradycardia B. Flattened neck veins C. Fever D. Crackles in the lungs

Correct Answer is D

Explanation

This is because crackles are a sign of fluid overload in the lungs, which can occur when a client receives too much IV fluid. Fluid overload can cause pulmonary edema, which is a life threatening condition that reduces oxygen exchange in the lungs. Some other signs and symptoms of fluid overload include rapid weight gain, swelling in the arms, legs and face, high blood pressure and shortness of breath.

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A nurse is caring for a client who is dying and having Cheyne-Stokes respirations. Which of the following respiratory findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is agitated and threatening to harm others. The nurse places the client in restraints, but does not notify the provider or obtain a prescription for the restraints. This situation represents which of the following torts?

Correct Answer is A

Explanation

A nurse is assessing a client who is receiving continuous IV fluids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing fluid overload?

Correct Answer is D

Explanation

A nurse hangs a bag of dextrose 5% in water 1,000 mL at 0800 to run at 125 mL/hr. At 1200, the nurse notices that the client's IV bag is empty. Which of the following interventions should the nurse take first?

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