A client is unconscious with a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

Correct Answer: C

Rationale: The correct answer is C: Cheyne-Stokes respirations. This breathing pattern is characterized by alternating periods of deep, rapid breathing (hyperventilation) followed by periods of apnea. This pattern is often seen in clients with neurological or cardiac conditions. Kussmaul respirations (A) are deep and rapid breathing associated with metabolic acidosis. Apneustic respirations (B) are characterized by prolonged inhalation and short, insufficient exhalation. Stridor (D) is a high-pitched, noisy breathing sound caused by obstructed air flow in the upper airway, not associated with the described breathing pattern.

Correct Answer: C

Rationale: The correct answer is C: Keep the drainage system below the level of the client's chest at all times. This is important to prevent backflow of air or fluid into the client's chest, which can lead to complications such as a pneumothorax or hemothorax. Gravity ensures that the drainage system functions properly and prevents any potential harm to the client. A: Clamping the chest tube prior to transferring the client is incorrect as it can cause a dangerous buildup of pressure in the chest. B: Disconnecting the chest tube from the drainage system can also lead to complications and disrupt the drainage process. D: Emptying the collection chamber is important but not the priority during transport; keeping the drainage system below the chest level is crucial for the client's safety.

Correct Answer: B

Rationale: The correct answer is B because facilitating the client's deep breathing is crucial post-CABG surgery to prevent complications such as atelectasis and pneumonia. Deep breathing helps improve lung expansion and oxygenation, promoting healing and preventing respiratory issues. A: While decreasing anxiety is important for overall well-being, it is not directly related to the client's recovery post-CABG surgery. C: Enhancing sleep is beneficial for healing, but it is not as critical as ensuring proper respiratory function in the immediate postoperative period. D: While reducing blood pressure may be desirable in some cases, it is not the most important effect to focus on post-CABG surgery; maintaining adequate oxygenation through deep breathing takes precedence.

Correct Answer: A

Rationale: Step 1: Movement of the trachea toward the unaffected side indicates tension pneumothorax, a life-threatening condition requiring immediate intervention. Step 2: This finding can lead to compromised breathing and hemodynamic instability if not addressed promptly. Step 3: B: Bubbling in the water seal chamber with exhalation is expected in a properly functioning chest tube system. Step 4: C: Crepitus at the insertion site is common due to air entering subcutaneous tissue during tube placement and is not an urgent concern. Step 5: D: Eyelets not visible can indicate dislodgement but is not as critical as tracheal deviation in this scenario.

Correct Answer: D

Rationale: The correct answer is D: Administer oxygen via nasal cannula. In a client with a sucking chest wound, the priority is to ensure adequate oxygenation due to potential respiratory compromise. Administering oxygen via nasal cannula will help improve oxygenation and support the client's respiratory function. This action takes precedence over other interventions as hypoxia can lead to further deterioration. A: Raising the foot of the bed to a 90° angle is not indicated in this situation as it does not address the immediate need for oxygenation. B: Removing the dressing to inspect the wound can worsen the condition by disrupting any seals in place to prevent air from entering the chest cavity. C: Preparing to insert a central line is not the priority in this situation as the client's respiratory status needs to be stabilized first.