In which client situation should the practical nurse assess for the presence of Cheyne-Stokes respirations?
With elevated blood glucose.
When death is imminent.
During an allergic reaction.
After strenuous exercise.
The Correct Answer is B
A. Elevated blood glucose is not typically associated with Cheyne-Stokes respirations. It might indicate diabetes or hyperglycemia but does not relate to this specific pattern of breathing.
B. Cheyne-Stokes respirations are often observed when death is imminent or in severe cases of terminal illness. This breathing pattern is characterized by cycles of increasing and decreasing respirations, often seen in end-of-life care.
C. An allergic reaction might cause respiratory symptoms, but it is not specifically associated with Cheyne-Stokes respirations. Assessing for Cheyne-Stokes would be more relevant in terminal or serious conditions rather than acute allergic reactions.
D. Cheyne-Stokes respirations are not related to strenuous exercise. After exercise, normal changes in breathing patterns occur, but Cheyne-Stokes respirations are indicative of more severe conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Explaining that the advanced directives form helps identify personal health care wishes for any future health event is crucial because it clarifies the importance of the form in planning for future health care decisions, even if the client is not currently ill.
B. Acknowledging the client’s concerns and notifying the healthcare provider is less immediate and does not directly address the client's understanding of the advanced directives form.
C. Asking a family member about the client's wishes is unnecessary since the client has communicated his own wishes and concerns, and the focus should be on informing the client about the form.
D. Documenting the client’s refusal is important but secondary to educating the client on the purpose and importance of advanced directives.
Correct Answer is C
Explanation
A. Notifying the charge nurse is important but should come after confirming the accurate heart rate assessment.
B. Holding a prescribed morning dose of digoxin may be necessary if bradycardia is confirmed, but the first step is to accurately assess the heart rate.
C. Obtaining a full minute apical pulse assessment is the first step to verify the radial pulse rate reported by the UAP and ensure an accurate and comprehensive assessment of the client's heart rate.
D. Reviewing the client's baseline vital signs is useful but should follow a thorough and accurate assessment of the current heart rate.
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