A nurse is evaluating an older adult client who is receiving end-of-life care and has Cheyne-Stokes respirations. Which of the following observations should the nurse identify as confirmation of this respiratory pattern?
An inability to breathe without dyspnea unless sitting upright
Shallow breathing alternating with periods of apnea
Breathing ranging from very deep to very shallow with periods of apnea
Rapid respirations that are unusually deep and regular
The Correct Answer is C
A. Inability to breathe without dyspnea unless sitting upright refers to a postural issue that might be seen in certain respiratory conditions but does not describe Cheyne-Stokes respirations.
B. Shallow breathing alternating with periods of apnea is not characteristic of Cheyne-Stokes respirations. While apnea does occur, the breathing pattern is more varied in depth.
C. Cheyne-Stokes respirations are characterized by a periodic pattern where the depth of breathing alternates between very deep and very shallow breaths, followed by periods of apnea. This is often seen in end-of-life care and is associated with respiratory distress or certain neurological conditions.
D. Rapid respirations that are unusually deep and regular are more consistent with Kussmaul respirations, which are typically seen in conditions like metabolic acidosis, not Cheyne-Stokes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Waiting 15 minutes after giving the cough syrup is unnecessary. There's typically no reason to delay giving tablets after a liquid medication unless specifically indicated.
B. Giving the cough syrup between the tablets is not an optimal approach, as it could result in potential interactions or interfere with absorption of the medications.
C. Administering the cough syrup first allows the liquid medication to be absorbed more quickly. Afterward, the tablets can be given with water to facilitate swallowing and ensure proper absorption. This order is generally most effective in promoting absorption and preventing interference between the two types of medication.
D. Administering the tablets first may lead to them being coated with the liquid, potentially delaying their absorption and effectiveness.
Correct Answer is C
Explanation
A. A pneumothorax occurs when there is a collapse of the lung due to air entering the pleural cavity, but this is not directly related to the lungs dropping below atmospheric pressure.
B. Air flows out of the lungs when the pressure inside the lungs is higher than atmospheric pressure (e.g., during exhalation).
C. When the pressure in the lungs drops below atmospheric pressure, it creates a vacuum effect, causing air to flow into the lungs during inhalation. This is how normal breathing works.
D. Bronchiolar constriction can cause respiratory distress, but it is not directly linked to a drop in lung pressure. Instead, constriction happens due to factors like asthma or allergies, not pressure changes.
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