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

Answer and Explanation

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.

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Correct Answer is "{\"xRanges\":[232.4270782470703,272.4270782470703],\"yRanges\":[382.1666450500488,422.1666450500488]}"

Explanation

To determine if the child is experiencing subcostal retractions, check the area beneath the ribcage.

D - Subcostal Area:

Subcostal retractions occur below the ribs and are a sign of respiratory distress, indicating increased effort to breathe.

Observing this area can reveal inward movement during inspiration, suggesting difficulty in breathing, often seen in asthma exacerbations.

Rationale

A - Incorrect:

This area is near the clavicle and not related to subcostal retractions.

B - Incorrect:

This is the intercostal area, which can also show retractions but is not subcostal.

C - Incorrect:

This area is too central and does not correspond with subcostal retractions.

Focusing on D allows the nurse to assess the presence of subcostal retractions effectively.

A. Talk about the special features of the baby with the client. B. Post a sign indicating No Visitors. C. Limit the amount of time the client is allowed to have the baby in her room. D. Tell the parents they should hold their baby.

Correct Answer is A

Explanation

A) Talk about the special features of the baby with the client: This intervention acknowledges the baby as a real person and can provide comfort to the grieving parents by validating their loss and giving them a chance to create memories, which is an important aspect of the grieving process.

B) Post a sign indicating No Visitors: This may not be appropriate as it might isolate the client further. Some parents may want the support of family and friends during this difficult time, and such a restriction should be based on the parents' wishes rather than a standard protocol.

C) Limit the amount of time the client is allowed to have the baby in her room: Allowing parents to spend as much time as they need with their baby can help them with the grieving process. Placing limits might be perceived as insensitive and could hinder the emotional healing process.

D) Tell the parents they should hold their baby: While many parents find comfort in holding their stillborn baby, it should be offered as a choice rather than a directive. It is important to respect the parents' individual coping mechanisms and provide support based on their preferences.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is "{\"xRanges\":[232.4270782470703,272.4270782470703],\"yRanges\":[382.1666450500488,422.1666450500488]}"

Explanation

A nurse is developing a plan of care for a client who delivered a stillborn fetus following a placental abruption. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

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