Silvestri: Saunders Comprehensive Review for the NCLEX-RN® Exami
b b b b b b b
nation, 5th Edition
b b
NursingbSciences
TestbBank
MULTIPLEbCHOICE
1.
Thebclientbwithbdiabetesbmellitusbhasbabbloodbglucoseblevelbonbadmissionbofb596bm
g/dL.bThebnursebanticipatesbthatbthisbclientbwouldbbebexperiencingbwhichbofbthebfollowingbt
ypesbofbacid-basebimbalance?
1. Metabolicbacidosis
2. Metabolicbalkalosis
3. Respiratorybacidosis
4. Respiratorybalkalosis
ANS: 1
Rationale:bDiabetesbmellitusbcanbleadbtobmetabolicbacidosis.bWhenbthebbodybdoesbnotbhave
bsufficientbcirculatingbinsulin,bthebbloodbglucoseblevelbrisesbwhilebthebcellsbofbthebbodybuseb
allbavailablebglucosebandbthenbbreakbdownbglycogenbandbfatbforbfuel.bThebby-productsbofbfa
tbmetabolismbarebacidotic,bleadingbtobthebcomplicationbcalledbdiabeticbketoacidosis.
Test-TakingbStrategy:bThebstrategicbwordsbinbthebquestionbareb“diabetesbmellitus.”bThisbte
llsbyoubthatbthebprimarybproblembisbmetabolicbinbnaturebratherbthanbrespiratory,bthusbelimin
atingb“respiratorybacidosis”bandb“respiratorybalkalosis.”bUsebknowledgebofbacid-basebconc
eptsbtobchoosebcorrectlybbetweenbthebtwobremainingboptions.bReviewbthebcomplicationsbofb
diabetesbmellitusbifbyoubhadbdifficultybwithbthisbquestion.
PTS: 1
DIF: LevelbofbCognitivebAbility:bAnalyzing
REF:
Ignatavicius,bD.,b&bWorkman,bM.b(2010).bMedical-surgicalbnursing:bpatient-cente
redbcollaborativebcareb(6thbed.).bSt.bLouis:bSaunders.
OBJ: ClientbNeeds:bPhysiologicalbIntegrity
TOP: ContentbArea:bNursingbSciences
MSC: IntegratedbProcess:bNursingbProcess—Assessment
2.
ThebnursebisbadmittingbabclientbwithbabdiagnosisbofbGuillain-Barrébsyndromebtobtheb
hospital.bThebnursebknowsbthatbifbthebdiseasebisbseverebenough,bthebclientbwillbbebatbriskbforb
whichbofbthebfollowingbacid-basebimbalances?
1. Metabolicbacidosis
2. Metabolicbalkalosis
3. Respiratorybacidosis
4. Respiratorybalkalosis
Elsevierbitemsbandbderivedbitemsb©b2011,b2008,b2005,b2002bbybSaunders,banbimprintbofbElsevierbInc.
, TestbBank 2
ANS: 3
Rationale:bGuillain-Barrébisbabneuromuscularbdisorderbinbwhichbthebclientbmaybexperience
bweakeningborbparalysisbofbthebmusclesbusedbforbrespiration.bThisbcouldbcausebthebclient btob
retainbcarbonbdioxide,bleadingbtobrespiratorybacidosisbandbventilatorybfailurebasbthebparalys
isbdevelops.bThereforeb“metabolicbacidosis,”b“metabolicbalkalosis,”bandb“respiratorybalkal
osis”barebincorrect.
Test-TakingbStrategy:bRecallbthatbthisbdisorderbimpairsbthebclient’sbrespiratorybfunction,bs
obeliminateb“metabolicbacidosis”bandb“metabolicbalkalosis”bfirst.bThinkingbthroughbthebeff
ectsbofbreducedbventilationbwillbhelpbyoubchoosebcorrectlybbetweenbthebremainingbtwobopti
ons.bReviewbthebmanifestationsbofbGuillain-Barrébsyndromebifbyoubhadbdifficultybwithbthisb
question.
PTS: 1
DIF: LevelbofbCognitivebAbility:bAnalyzing
REF:
Ignatavicius,bD.,b&bWorkman,bM.b(2010).bMedical-surgicalbnursing:bpatient-cente
redbcollaborativebcareb(6thbed.).bSt.bLouis:bSaunders.
OBJ: ClientbNeeds:bPhysiologicalbIntegrity
TOP: ContentbArea:bNursingbSciences
MSC: IntegratedbProcess:bNursingbProcess—Assessment
3.
Abclientbisbdeterminedbtobbebinbrespiratorybalkalosisbbybbloodbgasbanalysis.bThebnur
sebwouldbmonitorbthisbclientbforbsignsbofbwhichbofbthebfollowingbelectrolytebdisordersbthatbc
ouldbaccompanybthebacid-basebimbalance?
1. Hypokalemia
2. Hypercalcemia
3. Hypochloremia
4. Hypernatremia
ANS: 1
Rationale:bClinicalbmanifestationsbofbrespiratorybalkalosisbincludebtachypnea,bhyperpnea,b
weakness,bparesthesias,btetany,bdizziness,bconvulsions,bcoma,bhypokalemia,bandbhypocalc
emia.bThebclinicalbpicturebdoesbnotbincludebhypernatremia,bhypercalcemia,borbhypochlore
mia.
Test-TakingbStrategy:bTobanswerbthisbquestionbaccurately,byoubmustbbebfamiliarbwithbresp
iratorybalkalosisbandbitsbclinicalbsignsbandbsymptoms.bThisbwillballowbyoubtobeliminatebeac
hbofbthebincorrectbelectrolytebdisturbances.bUnderstandingbthatbserumbpotassiumbreductionb
occursbinbanbattemptbtobmaintainbelectroneutralitybinbthebpresencebofbalkalosisbwillbdirectby
oubtob“hypokalemia.”bIfbthisbquestionbwasbdifficult,breviewbthebphysiologicalbmechanismsb
thatboccurbinbrespiratorybalkalosis.
PTS: 1
Elsevierbitemsbandbderivedbitemsb©b2011,b2008,b2005,b2002bbybSaunders,banbimprintbofbElsevierbInc.
, TestbBank 3
DIF: LevelbofbCognitivebAbility:bAnalyzing
REF:
Ignatavicius,bD.,b&bWorkman,bM.b(2010).bMedical-surgicalbnursing:bpatient-cente
redbcollaborativebcareb(6thbed.).bSt.bLouis:bSaunders.
OBJ: ClientbNeeds:bPhysiologicalbIntegrity
TOP: ContentbArea:bNursingbSciences
MSC: IntegratedbProcess:bNursingbProcess—Assessment
4.
Thebclientbwithbabchronicbairflowblimitationb(CAL)bisbexperiencingbrespiratorybacid
osisbasbabcomplication.bThebnursebwhobisbtryingbtobenhancebthebclient’sbrespiratorybstatusbw
ouldbavoidbdoingbwhichbofbthebfollowing?
1. Keepingbthebheadbofbthebbedbelevated
2. Monitoringbthebflowbratebofbsupplementalboxygen
3. Assistingbthebclientbtobturn,bcough,bandbbreathebdeeply
4. Encouragingbthebclientbtobbreathebslowlybandbshallowly
ANS: 4
Rationale:bThebclientbwithbrespiratorybacidosisbisbexperiencingbelevatedbcarbonbdioxideble
velsbcausedbbybinsufficientbventilation.bThebnursebwouldbencouragebthebclientbtobbreathebsl
owlybandbdeeplybtobexpandbalveolibandbtobpromotebbetterbgasbexchange.bThebactionsblistedb
inb“keepingbthebheadbofbthebbedbelevated,”b“monitoringbthebflowbratebofbsupplementalboxyg
en,”bandb“assistingbthebclientbtobturn,bcough,bandbbreathebdeeply”barebhelpfulbactionsbonbthe
bpartbofbthebnurse.
Test-TakingbStrategy:bNotebthatbthebquestionbcontainsbthebstrategicbwordb“avoid.”bThisbw
ordbindicatesbabnegativebeventbquerybandbthebneedbtobselectbthebincorrectboption.bWithbthisbi
nbmind,beliminateboptionsbthatbarebbeneficialbtobairwaybstatus,bandbchoosebthebonebthatbwou
ldbcausebfurtherbimpairment.bNotingbthebstrategicbwordb“shallowly”binb“encouragingbthebcl
ientbtobbreathebslowlybandbshallowly”bwillbdirectbyoubtobthisboption.bReviewbcarebofbthebclie
ntbwithbrespiratorybacidosisbifbyoubhadbdifficultybwithbthisbquestion.
PTS: 1
DIF: LevelbofbCognitivebAbility:bApplying
REF:
Ignatavicius,bD.,b&bWorkman,bM.b(2010).bMedical-surgicalbnursing:bpatient-cente
redbcollaborativebcareb(6thbed.).bSt.bLouis:bSaunders.
OBJ: ClientbNeeds:bPhysiologicalbIntegrity
TOP: ContentbArea:bNursingbSciences
MSC: IntegratedbProcess:bNursingbProcess—Implementation
5.
Anbanxiousbclientbisbexperiencingbrespiratorybalkalosisbfrombhyperventilationbcaus
edbbybanxiety.bThebnursebwouldbdobwhichbofbthebfollowingbtobhelpbthebclientbexperiencingbt
hisbacid-basebdisorder?
1. Putbthebclientbinbabsupinebposition.
2. Providebemotionalbsupportbandbreassurance.
Elsevierbitemsbandbderivedbitemsb©b2011,b2008,b2005,b2002bbybSaunders,banbimprintbofbElsevierbInc.
b b b b b b b
nation, 5th Edition
b b
NursingbSciences
TestbBank
MULTIPLEbCHOICE
1.
Thebclientbwithbdiabetesbmellitusbhasbabbloodbglucoseblevelbonbadmissionbofb596bm
g/dL.bThebnursebanticipatesbthatbthisbclientbwouldbbebexperiencingbwhichbofbthebfollowingbt
ypesbofbacid-basebimbalance?
1. Metabolicbacidosis
2. Metabolicbalkalosis
3. Respiratorybacidosis
4. Respiratorybalkalosis
ANS: 1
Rationale:bDiabetesbmellitusbcanbleadbtobmetabolicbacidosis.bWhenbthebbodybdoesbnotbhave
bsufficientbcirculatingbinsulin,bthebbloodbglucoseblevelbrisesbwhilebthebcellsbofbthebbodybuseb
allbavailablebglucosebandbthenbbreakbdownbglycogenbandbfatbforbfuel.bThebby-productsbofbfa
tbmetabolismbarebacidotic,bleadingbtobthebcomplicationbcalledbdiabeticbketoacidosis.
Test-TakingbStrategy:bThebstrategicbwordsbinbthebquestionbareb“diabetesbmellitus.”bThisbte
llsbyoubthatbthebprimarybproblembisbmetabolicbinbnaturebratherbthanbrespiratory,bthusbelimin
atingb“respiratorybacidosis”bandb“respiratorybalkalosis.”bUsebknowledgebofbacid-basebconc
eptsbtobchoosebcorrectlybbetweenbthebtwobremainingboptions.bReviewbthebcomplicationsbofb
diabetesbmellitusbifbyoubhadbdifficultybwithbthisbquestion.
PTS: 1
DIF: LevelbofbCognitivebAbility:bAnalyzing
REF:
Ignatavicius,bD.,b&bWorkman,bM.b(2010).bMedical-surgicalbnursing:bpatient-cente
redbcollaborativebcareb(6thbed.).bSt.bLouis:bSaunders.
OBJ: ClientbNeeds:bPhysiologicalbIntegrity
TOP: ContentbArea:bNursingbSciences
MSC: IntegratedbProcess:bNursingbProcess—Assessment
2.
ThebnursebisbadmittingbabclientbwithbabdiagnosisbofbGuillain-Barrébsyndromebtobtheb
hospital.bThebnursebknowsbthatbifbthebdiseasebisbseverebenough,bthebclientbwillbbebatbriskbforb
whichbofbthebfollowingbacid-basebimbalances?
1. Metabolicbacidosis
2. Metabolicbalkalosis
3. Respiratorybacidosis
4. Respiratorybalkalosis
Elsevierbitemsbandbderivedbitemsb©b2011,b2008,b2005,b2002bbybSaunders,banbimprintbofbElsevierbInc.
, TestbBank 2
ANS: 3
Rationale:bGuillain-Barrébisbabneuromuscularbdisorderbinbwhichbthebclientbmaybexperience
bweakeningborbparalysisbofbthebmusclesbusedbforbrespiration.bThisbcouldbcausebthebclient btob
retainbcarbonbdioxide,bleadingbtobrespiratorybacidosisbandbventilatorybfailurebasbthebparalys
isbdevelops.bThereforeb“metabolicbacidosis,”b“metabolicbalkalosis,”bandb“respiratorybalkal
osis”barebincorrect.
Test-TakingbStrategy:bRecallbthatbthisbdisorderbimpairsbthebclient’sbrespiratorybfunction,bs
obeliminateb“metabolicbacidosis”bandb“metabolicbalkalosis”bfirst.bThinkingbthroughbthebeff
ectsbofbreducedbventilationbwillbhelpbyoubchoosebcorrectlybbetweenbthebremainingbtwobopti
ons.bReviewbthebmanifestationsbofbGuillain-Barrébsyndromebifbyoubhadbdifficultybwithbthisb
question.
PTS: 1
DIF: LevelbofbCognitivebAbility:bAnalyzing
REF:
Ignatavicius,bD.,b&bWorkman,bM.b(2010).bMedical-surgicalbnursing:bpatient-cente
redbcollaborativebcareb(6thbed.).bSt.bLouis:bSaunders.
OBJ: ClientbNeeds:bPhysiologicalbIntegrity
TOP: ContentbArea:bNursingbSciences
MSC: IntegratedbProcess:bNursingbProcess—Assessment
3.
Abclientbisbdeterminedbtobbebinbrespiratorybalkalosisbbybbloodbgasbanalysis.bThebnur
sebwouldbmonitorbthisbclientbforbsignsbofbwhichbofbthebfollowingbelectrolytebdisordersbthatbc
ouldbaccompanybthebacid-basebimbalance?
1. Hypokalemia
2. Hypercalcemia
3. Hypochloremia
4. Hypernatremia
ANS: 1
Rationale:bClinicalbmanifestationsbofbrespiratorybalkalosisbincludebtachypnea,bhyperpnea,b
weakness,bparesthesias,btetany,bdizziness,bconvulsions,bcoma,bhypokalemia,bandbhypocalc
emia.bThebclinicalbpicturebdoesbnotbincludebhypernatremia,bhypercalcemia,borbhypochlore
mia.
Test-TakingbStrategy:bTobanswerbthisbquestionbaccurately,byoubmustbbebfamiliarbwithbresp
iratorybalkalosisbandbitsbclinicalbsignsbandbsymptoms.bThisbwillballowbyoubtobeliminatebeac
hbofbthebincorrectbelectrolytebdisturbances.bUnderstandingbthatbserumbpotassiumbreductionb
occursbinbanbattemptbtobmaintainbelectroneutralitybinbthebpresencebofbalkalosisbwillbdirectby
oubtob“hypokalemia.”bIfbthisbquestionbwasbdifficult,breviewbthebphysiologicalbmechanismsb
thatboccurbinbrespiratorybalkalosis.
PTS: 1
Elsevierbitemsbandbderivedbitemsb©b2011,b2008,b2005,b2002bbybSaunders,banbimprintbofbElsevierbInc.
, TestbBank 3
DIF: LevelbofbCognitivebAbility:bAnalyzing
REF:
Ignatavicius,bD.,b&bWorkman,bM.b(2010).bMedical-surgicalbnursing:bpatient-cente
redbcollaborativebcareb(6thbed.).bSt.bLouis:bSaunders.
OBJ: ClientbNeeds:bPhysiologicalbIntegrity
TOP: ContentbArea:bNursingbSciences
MSC: IntegratedbProcess:bNursingbProcess—Assessment
4.
Thebclientbwithbabchronicbairflowblimitationb(CAL)bisbexperiencingbrespiratorybacid
osisbasbabcomplication.bThebnursebwhobisbtryingbtobenhancebthebclient’sbrespiratorybstatusbw
ouldbavoidbdoingbwhichbofbthebfollowing?
1. Keepingbthebheadbofbthebbedbelevated
2. Monitoringbthebflowbratebofbsupplementalboxygen
3. Assistingbthebclientbtobturn,bcough,bandbbreathebdeeply
4. Encouragingbthebclientbtobbreathebslowlybandbshallowly
ANS: 4
Rationale:bThebclientbwithbrespiratorybacidosisbisbexperiencingbelevatedbcarbonbdioxideble
velsbcausedbbybinsufficientbventilation.bThebnursebwouldbencouragebthebclientbtobbreathebsl
owlybandbdeeplybtobexpandbalveolibandbtobpromotebbetterbgasbexchange.bThebactionsblistedb
inb“keepingbthebheadbofbthebbedbelevated,”b“monitoringbthebflowbratebofbsupplementalboxyg
en,”bandb“assistingbthebclientbtobturn,bcough,bandbbreathebdeeply”barebhelpfulbactionsbonbthe
bpartbofbthebnurse.
Test-TakingbStrategy:bNotebthatbthebquestionbcontainsbthebstrategicbwordb“avoid.”bThisbw
ordbindicatesbabnegativebeventbquerybandbthebneedbtobselectbthebincorrectboption.bWithbthisbi
nbmind,beliminateboptionsbthatbarebbeneficialbtobairwaybstatus,bandbchoosebthebonebthatbwou
ldbcausebfurtherbimpairment.bNotingbthebstrategicbwordb“shallowly”binb“encouragingbthebcl
ientbtobbreathebslowlybandbshallowly”bwillbdirectbyoubtobthisboption.bReviewbcarebofbthebclie
ntbwithbrespiratorybacidosisbifbyoubhadbdifficultybwithbthisbquestion.
PTS: 1
DIF: LevelbofbCognitivebAbility:bApplying
REF:
Ignatavicius,bD.,b&bWorkman,bM.b(2010).bMedical-surgicalbnursing:bpatient-cente
redbcollaborativebcareb(6thbed.).bSt.bLouis:bSaunders.
OBJ: ClientbNeeds:bPhysiologicalbIntegrity
TOP: ContentbArea:bNursingbSciences
MSC: IntegratedbProcess:bNursingbProcess—Implementation
5.
Anbanxiousbclientbisbexperiencingbrespiratorybalkalosisbfrombhyperventilationbcaus
edbbybanxiety.bThebnursebwouldbdobwhichbofbthebfollowingbtobhelpbthebclientbexperiencingbt
hisbacid-basebdisorder?
1. Putbthebclientbinbabsupinebposition.
2. Providebemotionalbsupportbandbreassurance.
Elsevierbitemsbandbderivedbitemsb©b2011,b2008,b2005,b2002bbybSaunders,banbimprintbofbElsevierbInc.
