A nurse is assessing a client who has acute kidney failure and is in a state of metabolic acidosis. The nurse should monitor for which of the following manifestations?
Bounding peripheral pulses
Hyperreflexia
Cool skin
Hypotension
The Correct Answer is D
A) Bounding peripheral pulses: Metabolic acidosis typically does not cause bounding peripheral pulses. In metabolic acidosis, vasodilation might occur, but it usually leads to weaker, not bounding, pulses due to decreased cardiac output and blood pressure.
B) Hyperreflexia: Hyperreflexia is not commonly associated with metabolic acidosis. Instead, metabolic acidosis may cause symptoms like muscle weakness or fatigue due to the effect of acid-base imbalance on neuromuscular function.
C) Cool skin: While cool skin can sometimes be associated with poor perfusion in severe cases, it is not a direct manifestation of metabolic acidosis. Metabolic acidosis more commonly affects internal physiology rather than peripheral skin temperature directly.
D) Hypotension: Hypotension is a common manifestation of metabolic acidosis. The acidosis leads to vasodilation and decreased cardiac contractility, resulting in a drop in blood pressure. This is a critical sign for the nurse to monitor as it indicates the severity of the acid-base imbalance and its effect on the cardiovascular system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Drink 8 oz of milk when hypoglycemia develops:
While consuming a fast-acting carbohydrate is important during hypoglycemia, 8 oz of milk may not be the most effective choice. Typically, glucose tablets or juice are recommended as they provide a quicker absorption of sugar into the bloodstream.
B) Initiate a 1,400-calorie diet daily:
Caloric needs should be individualized based on the adolescent’s age, weight, activity level, and overall health. A fixed 1,400-calorie diet might not be appropriate for every adolescent and could lead to insufficient energy intake or excessive restriction.
C) Rotate the insulin injection site to a different area of the body with every other injection:
While rotating injection sites is important to prevent lipodystrophy, it is generally recommended to use different sites within the same area (such as different spots on the abdomen) rather than entirely different areas of the body with each injection. This ensures consistent absorption of insulin.
D) Keep unopened insulin refrigerated at 4.44° C (40° F):
Unopened insulin should be stored in the refrigerator to maintain its potency until it is ready to be used. This temperature range ensures the insulin remains stable and effective for use.
Correct Answer is D
Explanation
A) "I will remain in the hospital until my treatment is completed.": Hospitalization is not typically required for the entire duration of tuberculosis (TB) treatment. Most patients with TB can continue their treatment at home with proper medication and infection control measures, unless they have severe disease or complications.
B) "I will wear a surgical mask around my family.": A surgical mask is not sufficient to protect others from TB. Patients with active TB should wear an N95 respirator mask to reduce the risk of spreading the infection, especially in situations where close contact is unavoidable.
C) "I will need medication to treat my condition for the rest of my life.": TB treatment generally involves a course of medication lasting 6 to 9 months. Long-term, lifelong medication is not required; however, adherence to the full course of prescribed antibiotics is crucial to ensure the infection is fully eradicated.
D) "I will need to provide a sputum specimen every 4 weeks until I test negative.": Monitoring sputum samples every 4 weeks is a standard practice to assess the effectiveness of TB treatment and confirm that the patient is no longer infectious. This statement indicates an understanding of the ongoing evaluation needed during treatment.
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