During an assessment of the respiratory pattern of an older adult client receiving end-of-life care, which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?

Correct Answer: A

Rationale: The correct answer is A because Cheyne-Stokes respirations are characterized by a pattern of breathing that ranges from very deep to very shallow with periods of apnea. This pattern reflects an abnormal breathing cycle that is often seen in end-of-life care or in patients with severe neurological problems. Choice B is incorrect because it describes a pattern of shallow to normal breaths alternating with periods of apnea, which is not characteristic of Cheyne-Stokes respirations. Choice C is incorrect as it describes rapid respirations that are unusually deep and regular, which is not consistent with the pattern of Cheyne-Stokes respirations. Choice D is also incorrect because it describes an inability to breathe without dyspnea unless sitting upright, which is not a characteristic of Cheyne-Stokes respirations.

Correct Answer: D

Rationale: The correct answer is D, placing the client in a prone position. This intervention optimizes oxygenation by improving ventilation-perfusion matching in ARDS. When the client is in a prone position, there is better distribution of ventilation to the dorsal lung regions, reducing the risk of ventilator-induced lung injury. Choice A is incorrect because low-flow oxygen may not be sufficient to meet the oxygen demands of a client with ARDS. Choice B is incorrect because excessive oral intake can lead to fluid overload in ARDS. Choice C is incorrect because high-protein and high-carbohydrate foods may be difficult for the client to tolerate and can contribute to increased carbon dioxide production.

Correct Answer: B

Rationale: The correct answer is B: Increasing dyspnea. Atelectasis is a condition where the lung tissue collapses, leading to decreased oxygen exchange and resulting in symptoms like dyspnea (difficulty breathing). This occurs because the collapsed lung tissue reduces the surface area available for gas exchange, leading to decreased oxygen saturation and increased work of breathing. Facial flushing (choice A) is not typically associated with atelectasis. Decreasing respiratory rate (choice C) may not be a reliable indicator as the body may compensate by increasing respiratory rate to maintain oxygenation. Friction rub (choice D) is more commonly associated with conditions like pleurisy or pneumonia, not atelectasis.

Correct Answer: C

Rationale: The correct answer is C: Heparin. Heparin is a common anticoagulant used to prevent further clotting in patients with pulmonary embolism. It works by inhibiting blood clot formation. Furosemide (A) is a diuretic used for conditions like heart failure and edema, not for pulmonary embolism. Dexamethasone (B) is a corticosteroid used for inflammation and immune suppression, not for pulmonary embolism. Atropine (D) is used to treat bradycardia and not indicated for pulmonary embolism. Administering heparin is crucial to prevent worsening of the pulmonary embolism and potential life-threatening complications.

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.