Saunders Comprehensive Review for the NCLEX-RN Examination Silvestri 5th Edition Test Bank 6 MSC: Integrated Process: Nursing Process—Planning


7. The nurse is caring for a client who is experiencing metabolic alkalosis. The nurse plans to protect the client’s safety, knowing the risks of this imbalance, by carefully implementing which of the following prescribed precautions? 1. Contact isolation 2. Seizure precautions 3. Bleeding precautions 4. Neutropenic precautions


ANS: 2


Rationale: The client with metabolic alkalosis is at risk for tetany and seizures. The nurse would maintain client safety by using seizure precautions with this client. “Contact isolation,” “bleeding precautions,” and “neutropenic precautions” are unnecessary in the care of the client experiencing metabolic alkalosis.


Test-Taking Strategy: Use the process of elimination and knowledge of alkalotic effects to make your selection. Recalling that the client experiencing metabolic alkalosis is at risk for tetany and seizures will direct you to “seizure precautions.” If you had difficulty with this question, review this acid-base disorder.


PTS: 1 DIF: Level of Cognitive Ability: Applying REF: Copstead-Kirkhorn, L., & Banasik, J. (2010). Pathophysiology (4th ed.). St. Louis: Mosby. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Nursing Sciences MSC: Integrated Process: Nursing Process—Planning


8. The nurse is caring for a client who overdosed on acetylsalicylic acid (aspirin) 24 hours ago. The nurse expects to note which of the following findings associated with an anticipated acid-base disturbance? 1. Disorientation and dyspnea 2. Drowsiness, headache, and tachypnea 3. Tachypnea, dizziness, and paresthesias 4. Decreased respiratory rate and depth, cardiac irregularities


ANS: 2


Rationale: The client who ingests a large amount of acetylsalicylic acid (aspirin) is at risk for developing metabolic acidosis 24 hours later. If metabolic acidosis occurs, the client is likely to exhibit drowsiness, headache, and tachypnea. In the very early hours following aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. However, by 24 hours postoverdose, the compensatory mechanism fails and the client reverts to metabolic acidosis. The client with metabolic alkalosis (“decreased respiratory rate and depth, cardiac irregularities”) is likely to experience cardiac irregularities and a compensatory decreased respiratory rate and


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


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