Page 2618 - Saunders Comprehensive Review For NCLEX-RN

Rationale: Lack of ability to cope effectively may be evidenced by a client’s
inability to meet basic needs, inability to meet role expectations, alteration in social
participation, use of inappropriate defense mechanisms, or impairment of usual
patterns of communication. Anxiety is a broad description and can occur as a result
of many triggers; although the client was experiencing anxiety, the client’s concern
now is the ability to meet role expectations and financial obligations. There is no
information in the question that indicates an unrealistic outlook or disturbances in
thoughts and ideas.
Test-Taking Strategy: Note the strategic word, priority. Focus on the subject,
concerns regarding the ability to meet role expectations and financial obligations.
Option 1 can be eliminated because the client was previously experiencing anxiety.
Eliminate options 2 and 4 because there are no data in the question that address
these problems.
Level of Cognitive Ability: Creating
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process—Planning
Content Area: Mental Health
Health Problem: Mental Health: Anxiety disorders
Priority Concepts: Anxiety; Coping
Reference: Varcarolis (2017), pp. 142-143.

943. Answer: 2

Rationale: Bubbling in the water seal chamber is caused by air passing out of the
pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is
normal. It indicates that the system is accomplishing one of its purposes, removing
air from the pleural space. Continuous bubbling during inspiration and expiration
indicates that an air leak exists. If this occurs, it must be corrected. Notifying the
primary health care provider and changing the chest tube drainage system are not
indicated at this time.
Test-Taking Strategy: Note the strategic words, most appropriate. Note the subject,
chest tube drainage systems, and focus on the words intermittent bubbling and water
seal chamber. Recalling that intermittent (not constant) bubbling is normal in this
chamber will direct you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Skills: Tube care
Health Problem: N/A
Priority Concepts: Clinical Judgment; Gas Exchange
Reference: Lewis et al. (2017), p. 525.

944. Answer: 1

Rationale: Although frequency and intensity of bowel sounds vary depending on
the phase of digestion, normal bowel sounds are relatively high-pitched clicks or
gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly

2618