A nurse is discussing with a patient who has reported acute lower back pain after lifting heavy boxes. What information should the nurse emphasize?

Choice A rationale
Turning the patient on their side before starting oral care is a recommended practice when caring for an unresponsive patient. This position helps prevent aspiration, which can occur if the patient cannot swallow properly.
Choice B rationale
Applying petroleum jelly to the patient’s lips after oral care can help prevent dryness and cracking. However, it’s not the primary action the nurse should take when performing oral hygiene for an unresponsive patient.
Choice C rationale
Using the thumb and index finger to keep the patient’s mouth open is not recommended. It can cause discomfort and potential injury to the patient.
Choice D rationale
Using a stiff toothbrush to clean the patient’s teeth is not recommended. A soft toothbrush is usually used to clean the teeth of an unresponsive patient to prevent damage to the gums.

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.