Page 291 - Saunders Comprehensive Review For NCLEX-RN

Health Problem: Adult Health: Gastrointestinal: Upper GI Disorder
Priority Concepts: Acid-Base Balance; Clinical Judgment
Reference: Ignatavicius, Workman, Rebar (2018), p. 196.

56. Answer: 4

Rationale: Clients experiencing nausea and vomiting would most likely present
with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and
HCO – to increase. Symptoms experienced by the client would include a decrease in
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the respiratory rate and depth, and tachycardia. Option 1 reflects a respiratory
acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3
reflects a metabolic acidotic condition.
Test-Taking Strategy: Focus on the subject, expected arterial blood gas findings.
Note the data in the question and that the client is vomiting. Recalling that vomiting
most likely causes metabolic alkalosis will assist in directing you to the correct
option.
Level of Cognitive Ability: Synthesizing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Foundations of Care: Acid-Base
Health Problem: Adult Health: Gastrointestinal: Upper GI Disorder
Priority Concepts: Acid-Base Balance; Clinical Judgment
Reference: Lewis et al. (2017), p. 288.

57. Answer: 4

Rationale: The ABG values are abnormal, which supports a physiological
problem. The ABGs indicate respiratory alkalosis as a result of hyperventilating, not
acidosis. Concluding that the client is overreacting is an inaccurate analysis. No
conclusion can be made about a client’s fluid volume status from the information
provided.
Test-Taking Strategy: Focus on the data in the question. Note the ABG values and
use knowledge to interpret them. Note that the pH is elevated and the Paco is
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decreased from normal. This will assist you in determining that the client is
experiencing respiratory alkalosis. Next, think about the causes of respiratory
alkalosis to answer correctly.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Analysis
Content Area: Foundations of Care: Acid-Base
Health Problem: Mental Health: Anxiety Disorder
Priority Concepts: Acid-Base Balance; Clinical Judgment
Reference: Lewis et al. (2017), p. 288.

58. Answer: 2, 4

Rationale: Kussmaul’s respirations are abnormally deep and increased in rate.

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