Nclex

The nurse learns in report that a client is exhibiting Cheyne-Stokes respirations. Based on this data, which action is most appropriate for the nurse to take initially? - Determine the client's ability to follow verbal commands. Cheyne-Stokes respirations, rhythmic respirations with periods of apnea, occur with disorders affecting the respiratory center of the pons in the central nervous system such as a metabolic dysfunction in the cerebral hemisphere or basal ganglia. The nurse should initially obtain data about neurological functioning, starting with determining the client's ability to respond to verbal stimuli. Listening to heart sounds is important but is secondary to determining the neurological status. There is no information related to the need to check for a pulse deficit (difference between the apical and radial pulse). The use of incentive spirometry is indicated for shallow breathing and postoperatively. The nurse is checking the apical heart rate of a client with a complaint of angina. The nurse places the stethoscope in which anatomical area? Refer to figure. - 4 Rationale: The apical heart rate is assessed best by placing the stethoscope in the mitral area, which is located in the fifth intercostal space on the left side of the chest at the apex of the heart. The aortic area is located in the second intercostal space just right of the sternum. Erb's point is located in the third intercostal space just left of the sternum. The pulmonic area is located in the second intercostal space just left of the sternum.