Page 294 - Saunders Comprehensive Review For NCLEX-RN
P. 294
Test-Taking Strategy: Note the strategic words, most likely. Focus on the data in
the question and use knowledge about the interpretation of arterial blood gas values
to determine that the client is experiencing respiratory alkalosis. Next, recall the
manifestations that occur in this condition and the normal laboratory values. The
only abnormal laboratory value is the potassium level, the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Foundations of Care: Acid-Base
Health Problem: N/A
Priority Concepts: Acid-Base Balance; Clinical Judgment
Reference: Ignatavicius, Workman, Rebar (2018), pp. 195-196.
63. Answer: 1
Rationale: Respiratory acidosis is most often caused by hypoventilation. The
client with broken ribs will have difficulty with breathing adequately and is at risk
for hypoventilation and resultant respiratory acidosis. The remaining options are
incorrect. Respiratory alkalosis is associated with hyperventilation. There are no data
in the question that indicate calcium loss or that the client is taking analgesics
containing base products.
Test-Taking Strategy: Note the strategic words, most likely. Focus on the data in
the question. Think about the location of the ribs to determine that the client will
have difficulty breathing adequately. This will assist in directing you to the correct
option. Remembering that hypoventilation results in respiratory acidosis will direct
you to the correct option.
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: Chest Injuries
Priority Concepts: Acid-Base Balance; Clinical Judgment
Reference: Lewis et al. (2017), p. 288.
294