A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.).
Lethargy.
Kussmaul's respirations.
Circumoral paresthesia.
Bicarbonate excess.
Flushing
Correct Answer : A,C,D
The correct answer is choice A, C, and D.
Choice A rationale:
Lethargy is a common symptom of metabolic alkalosis due to the body’s attempt to compensate for the altered pH balance, leading to decreased energy levels and fatigue.
Choice B rationale:
Kussmaul’s respirations are typically associated with metabolic acidosis, not alkalosis. These deep, labored breaths are the body’s way of trying to expel excess carbon dioxide to correct acidosis.
Choice C rationale:
Circumoral paresthesia, or tingling around the mouth, is a symptom of metabolic alkalosis. This occurs due to changes in calcium ion concentration affecting nerve function.
Choice D rationale:
Bicarbonate excess is a direct cause of metabolic alkalosis. Elevated bicarbonate levels in the blood lead to an increased pH, resulting in alkalosis.
Choice E rationale:
Flushing is not a typical symptom of metabolic alkalosis. It is more commonly associated with conditions that cause vasodilation or increased blood flow to the skin.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Hypokalemia is not a direct adverse effect of dextrose 10% in water infusion. This solution does not contain potassium, and unless the patient already has low potassium levels or other contributing factors, it would not cause hypokalemia.
Choice B rationale:
Hypercalcemia is unrelated to dextrose 10% in water infusion. The solution does not contain calcium, and it would not lead to an increase in serum calcium levels.
Choice C rationale:
Hypovolemia, or low blood volume, is not typically associated with dextrose 10% in water infusion. However, if administered rapidly in large amounts, it could potentially cause fluid overload leading to hypervolemia.
Choice D rationale:
Hyperglycemia is a possible adverse effect of dextrose 10% in water infusion. The solution contains a high concentration of glucose, which can raise blood sugar levels if the body cannot adequately utilize or regulate the glucose. Regular monitoring of blood glucose levels is essential during such an infusion, especially in patients with diabetes or impaired glucose tolerance.
Correct Answer is D
Explanation
The correct answer is choice D. The client who has gastroenteritis and is febrile.
Choice A rationale:
The client with end-stage renal failure scheduled for dialysis would not be at risk for fluid volume deficit because dialysis is a treatment that removes waste, salt, and extra water to prevent them from building up in the body, keeping a safe level of certain chemicals in the blood, and controlling blood pressure.
Choice B rationale:
Being NPO (nothing by mouth) since midnight for endoscopy typically involves a short period of fasting. While it could potentially contribute to a mild fluid volume deficit, it is not as significant as other causes like vomiting or diarrhea, which can lead to more substantial fluid losses.
Choice C rationale:
A client with left-sided heart failure and an elevated BNP level is more likely to experience fluid volume overload rather than a deficit. BNP is released in response to ventricular volume expansion and pressure overload, which are indicative of heart failure, not fluid volume deficit.
Choice D rationale:
The client with gastroenteritis and a fever is at risk for fluid volume deficit due to increased fluid losses from vomiting, diarrhea, and fever-induced perspiration. These symptoms align with the common risk factors for fluid volume deficit, which include vomiting, diarrhea, and sweating.
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