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.

Answer and Explanation

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.

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Correct Answer is ["A","B","D"]

Explanation

A. Oxygen Concentration of the Ambient Air
The oxygen concentration of the ambient air affects how much oxygen the child could have been exposed to once retrieved from the pool. If the child was submerged in water, the ability to access oxygen from the environment was compromised, which contributes to the level of hypoxemia experienced. Ambient air oxygen concentration is a crucial factor in determining how long it might take for hypoxemia to develop or improve after submersion.
B. Temperature of Water
The temperature of the water affects the child’s physiology during submersion. Cold water can lead to a more rapid decrease in core body temperature and can influence the child’s respiratory and cardiovascular responses, potentially affecting the degree of hypoxemia.
C. The Weight of the Child
The weight of the child does not significantly impact the level of hypoxemia experienced during submersion. While it might influence the child’s ability to stay afloat or the rescue process, it does not directly affect hypoxemia levels.
D. The Amount of Time the Child Was Submerged
The duration of submersion is a critical factor in determining the level of hypoxemia. Longer submersion times result in more significant oxygen deprivation and a greater degree of hypoxemia, which can impact the severity of respiratory and cardiac complications.
E. Whether or Not Anyone Witnessed the Fall into the Pool
While witnessing the fall might be relevant for understanding the context of the incident, it does not directly affect the level of hypoxemia experienced during the submersion. The key factors are related to the conditions and duration of the submersion itself

A. Give ibuprofen 400 mg PO every 6 hours PRN for fever B. Give 1,000 mL sodium chloride now C. Discontinue the peripheral IV D. Insert an indwelling urinary catheter E. Apply cardiac telemetry monitoring F. Collect blood to test electrolyte levels G. Prepare to defibrillate the client H. Collect blood for a type and screen

Correct Answer is ["A","E","F"]

Explanation

A. Give ibuprofen 400 mg PO every 6 hours PRN for fever
The client has a fever of 101.5° F (38.6° C), so administering ibuprofen to manage the fever is appropriate.
B. Give 1,000 mL sodium chloride now
This prescription is already ordered and being administered, so it does not need to be requested again.
C. Discontinue the peripheral IV
The client needs IV access for fluid administration and potential medications, so discontinuing the peripheral IV is not appropriate.
D. Insert an indwelling urinary catheter
There is no indication of urinary retention or need for precise fluid measurement, making this intervention unnecessary at this time.
E. Apply cardiac telemetry monitoring
Given the client's elevated heart rate and respiratory rate, cardiac telemetry monitoring would help in continuously assessing the client's cardiac status.
F. Collect blood to test electrolyte levels
Due to the client's symptoms and history of decreased fluid intake, electrolyte imbalance is a concern, and testing electrolyte levels is necessary.
G. Prepare to defibrillate the client
There is no indication of a cardiac emergency that would require defibrillation.
H. Collect blood for a type and screen
There is no indication of the need for a blood transfusion, making this intervention unnecessary.

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In which client situation should the practical nurse assess for the presence of Cheyne-Stokes respirations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits What factors are important in determining level of hypoxemia that the child may have experienced during the submersion? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

Exhibits Based on the current focused assessment, what prescriptions should the practical nurse (PN) ask the health care provider to add? Select all that apply.

Correct Answer is ["A","E","F"]

Explanation

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