Saunders Comprehensive Review for the NCLEX-RN Examination Silvestri 5th Edition Test Bank 4


TOP: Content Area: Nursing Sciences MSC: Integrated Process: Nursing Process—Assessment


4. The client with a chronic airflow limitation (CAL) is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client’s respiratory status would avoid doing which of the following? 1. Keeping the head of the bed elevated 2. Monitoring the flow rate of supplemental oxygen 3. Assisting the client to turn, cough, and breathe deeply 4. Encouraging the client to breathe slowly and shallowly


ANS: 4


Rationale: The client with respiratory acidosis is experiencing elevated carbon dioxide levels caused by insufficient ventilation. The nurse would encourage the client to breathe slowly and deeply to expand alveoli and to promote better gas exchange. The actions listed in “keeping the head of the bed elevated,” “monitoring the flow rate of supplemental oxygen,” and “assisting the client to turn, cough, and breathe deeply” are helpful actions on the part of the nurse.


Test-Taking Strategy: Note that the question contains the strategic word “avoid.” This word indicates a negative event query and the need to select the incorrect option. With this in mind, eliminate options that are beneficial to airway status, and choose the one that would cause further impairment. Noting the strategic word “shallowly” in “encouraging the client to breathe slowly and shallowly” will direct you to this option. Review care of the client with respiratory acidosis if you had difficulty with this question.


PTS: 1 DIF: Level of Cognitive Ability: Applying 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—Implementation


5. An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse would do which of the following to help the client experiencing this acid-base disorder? 1. Put the client in a supine position. 2. Provide emotional support and reassurance. 3. Withhold all sedative or antianxiety medications. 4. Tell the client to breathe very deeply but more slowly.


ANS: 2


Rationale: An anxious client benefits from emotional support and reassurance, which in turn reduces anxiety and may lower the respiratory rate. The client may benefit from the


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


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