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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A condom catheter is a urine collection device that fits like a condom over the penis and has a tube that goes to a collection bag strapped to the leg. To apply a condom catheter, the nurse should clean and dry the penis thoroughly, unroll the sheath over the penis, leaving 2.5 to 5 cm (1 to 2 in) of space between the end of the catheter and the tip ofthe penis, and gently squeeze the catheter around the penis shaft for 10 to 15 seconds to ensure adhesion.
Correct Answer is C
Explanation
The Weber's test is used to assess for unilateral hearing loss caused by either conduction or sensorineural impairment. The nurse places a vibrating tuning fork on the midline of the client's head and asks if he hears it better in one ear or equally in both ears. A normal finding is that the sound is heard equally in both ears (no lateralization). If there is conduction deafness in one ear, the sound will be heard louder in that ear (lateralization to affected ear). If there is sensorineural deafness in one ear, the sound will be heard louder in the opposite ear (lateralization to unaffected ear).
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