Page 2610 - Saunders Comprehensive Review For NCLEX-RN

Integrated Process: Nursing Process—Implementation
Content Area: Skills: Tube Care
Health Problem: N/A
Priority Concepts: Gas Exchange; Safety
Reference: Potter et al. (2017), p. 1178.

924. Answer: 3

Rationale: When a client is experiencing respiratory acidosis, the respiratory rate
and depth increase in an attempt to compensate. The client also experiences
headache; restlessness; mental status changes, such as drowsiness and confusion;
visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute;
hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not
specifically associated with this disorder.
Test-Taking Strategy: Focus on the subject, clinical manifestations associated with
respiratory acidosis, and use knowledge of the signs and symptoms of respiratory
acidosis to answer this question. Eliminate options 2 and 4 first because they are
comparable or alike and address a decreased respiratory rate. Remember that
headache, restlessness, and confusion occur in respiratory acidosis.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Foundations of Care: Acid–Base
Health Problem: Adult Health: Respiratory: Obstructive Pulmonary Disease
Priority Concepts: Acid–Base Balance; Clinical Judgment
Reference: Ignatavicius, Workman, Rebar (2018), pp. 192-193.

925. Answer: 4

Rationale: Distention, vomiting, and abdominal pain are a few of the symptoms
associated with intestinal obstruction. Nasogastric tubes may be used to remove gas
and fluid from the stomach, relieving distention and vomiting. Bowel sounds return
to normal as the obstruction is resolved and normal bowel function is restored.
Discontinuing the nasogastric tube before normal bowel function may result in a
return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum
electrolyte levels, pH of the gastric aspirate, and tube placement are important
assessments for the client with a nasogastric tube in place but would not assist in
determining the readiness for removing the nasogastric tube.
Test-Taking Strategy: Eliminate options 2 and 3 first because they are comparable
or alike. Assessing the pH of the gastric aspirate is one method of assessing tube
placement. Also, note the strategic word, priority. Focus on the client’s diagnosis to
direct you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: Lower GI disorders

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