Saunders Comprehensive Review for the NCLEX-RN Examination Silvestri 5th Edition Test Bank 3


Rationale: Guillain-Barré is a neuromuscular disorder in which the client may experience weakening or paralysis of the muscles used for respiration. This could cause the client to retain carbon dioxide, leading to respiratory acidosis and ventilatory failure as the paralysis develops. Therefore “metabolic acidosis,” “metabolic alkalosis,” and “respiratory alkalosis” are incorrect.


Test-Taking Strategy: Recall that this disorder impairs the client’s respiratory function, so eliminate “metabolic acidosis” and “metabolic alkalosis” first. Thinking through the effects of reduced ventilation will help you choose correctly between the remaining two options. Review the manifestations of Guillain-Barré syndrome if you had difficulty with this question.


PTS: 1 DIF: Level of Cognitive Ability: Analyzing REF: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient- centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Nursing Sciences MSC: Integrated Process: Nursing Process—Assessment


3. A client is determined to be in respiratory alkalosis by blood gas analysis. The nurse would monitor this client for signs of which of the following electrolyte disorders that could accompany the acid-base imbalance? 1. Hypokalemia 2. Hypercalcemia 3. Hypochloremia 4. Hypernatremia


ANS: 1


Rationale: Clinical manifestations of respiratory alkalosis include tachypnea, hyperpnea, weakness, paresthesias, tetany, dizziness, convulsions, coma, hypokalemia, and hypocalcemia. The clinical picture does not include hypernatremia, hypercalcemia, or hypochloremia.


Test-Taking Strategy: To answer this question accurately, you must be familiar with respiratory alkalosis and its clinical signs and symptoms. This will allow you to eliminate each of the incorrect electrolyte disturbances. Understanding that serum potassium reduction occurs in an attempt to maintain electroneutrality in the presence of alkalosis will direct you to “hypokalemia.” If this question was difficult, review the physiological mechanisms that occur in respiratory alkalosis.


PTS: 1 DIF: Level of Cognitive Ability: Analyzing REF: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient- centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity


Saunders Comprehensive Review for the NCLEX-RN Examination Silvestri 5th Edition Test Bank


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