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 D

Explanation

A) Decreased magnesium level: Primary aldosteronism typically affects sodium and potassium balance, but it is less likely to cause significant changes in magnesium levels. Therefore, a decreased magnesium level is not the expected electrolyte imbalance in this condition.

B) Decreased total calcium level: Primary aldosteronism does not primarily affect calcium metabolism. While calcium levels could be influenced indirectly, they are not a primary concern in this disorder. Hence, a decreased total calcium level is not expected.

C) Elevated phosphate level: Phosphate levels are generally not directly influenced by aldosterone. Elevated phosphate levels might be seen in other conditions, but they are not characteristic of primary aldosteronism.

D) Elevated sodium level: Primary aldosteronism leads to excess production of aldosterone, which promotes sodium retention by the kidneys. This retention causes elevated sodium levels, resulting in hypernatremia, and contributes to symptoms like frequent urination due to the body's attempt to excrete excess sodium through increased urine production.

A. Teach the client to void over a urine strainer. B. Administer oxybutynin to the client twice per day. C. Encourage frequent ambulation for the client. D. Check the client's urine for ketones three times per day. E. Instruct the client to drink 3 L of fluid per day.

Correct Answer is ["A","C","E"]

Explanation

A) Teach the client to void over a urine strainer: After lithotripsy, clients are often advised to void over a strainer to catch any small stone fragments that may pass. This helps in monitoring the passage of stone fragments and ensures that any remaining stones can be analyzed for further management.

B) Administer oxybutynin to the client twice per day: Oxybutynin is an anticholinergic medication used to treat bladder spasms. It is not routinely used after lithotripsy unless specifically prescribed for bladder spasms, which are not a common postoperative concern for this procedure.

C) Encourage frequent ambulation for the client: Frequent ambulation is beneficial after lithotripsy as it helps promote overall recovery, reduces the risk of complications like deep vein thrombosis, and can facilitate the passage of stone fragments. Encouraging movement is an essential aspect of postoperative care.

D) Check the client's urine for ketones three times per day: Monitoring for ketones is not typically required following lithotripsy unless there is a specific concern about diabetic ketoacidosis or another condition that warrants ketone monitoring. It is not a standard intervention for postoperative care after lithotripsy.

E) Instruct the client to drink 3 L of fluid per day: Increasing fluid intake is crucial after lithotripsy to help flush out any remaining stone fragments and to prevent new stone formation. Drinking 3 liters of fluid per day is generally recommended to maintain adequate hydration and support the urinary system.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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