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","B","E"]
Explanation
The nurse should secure restraints to allow three fingers to slide under the restraints to prevent circulation impairment and nerve damage. The nurse should also assess skin temperature and color before applying the restraints to establish a baseline and monitor for signs of ischemia. The nurse should ensure that the client's bed is in the lowest position to reduce the risk of injury from falls. The nurse should pad bony prominences before applying the restraints to prevent skin breakdown and pressure ulcers. The nurse should not attach the client's restraints to the bed rail because this can cause injury if the bed is moved or adjusted. The nurse should attach the restraints to a part of the bed frame that moves with the client, such as the mattress support platform.
Correct Answer is B
Explanation
A client identifier is a unique piece of information that can be used to verify the identity of a client before providing care or services. Using client identifiers helps to prevent errors and ensure patient safety. A photograph is an example of a client identifier that can be used by the nurse to confirm that they are administering the medication to the right person.
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