Saunders Comprehensive Review for the NCLEX-RN Examination Silvestri 5th Edition Test Bank 7


depth. “Disorientation and dyspnea” and “tachypnea, dizziness, and paresthesias” indicate respiratory acidosis and alkalosis, respectively.


Test-Taking Strategy: Note that the strategic words in the question are “24 hours ago.” Recalling that the client is at risk for metabolic acidosis will direct you to “drowsiness, headache, and tachypnea.” If this question was difficult, review the effects of aspirin overdose and the manifestations of metabolic acidosis.


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


9. A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse should monitor this client, expecting to note which of the following signs and symptoms? 1. Disorientation and dyspnea 2. Decreased respiratory rate and depth 3. Drowsiness, headache, and tachypnea 4. Tachypnea, dizziness, and paresthesias


ANS: 2


Rationale: The client with metabolic alkalosis is likely to exhibit decreased respiratory rate and depth as a compensatory mechanism. The client with metabolic acidosis would display the symptoms noted in “drowsiness, headache, and tachypnea.” The client with respiratory acidosis and alkalosis would display the symptoms noted in “disorientation and dyspnea” and “tachypnea, dizziness, and paresthesias” respectively.


Test-Taking Strategy: To answer this question accurately, you must be familiar with the signs and symptoms exhibited by the client with metabolic alkalosis. Remember that decreased respiratory rate and depth occur in metabolic acidosis. If this question was difficult, review the manifestations of metabolic acidosis.


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


10. The nurse enters a client’s room to check the client who began receiving a blood transfusion 45 minutes earlier. The client is dyspneic and has a bounding pulse. The nurse listens to the client’s lung sounds and notes the presence of crackles in the lung


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


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21