A nurse is caring for a client who is experiencing severe nausea and vomiting after a course of chemotherapy. The nurse should monitor the client for which of the following clinical manifestations?
Metabolic acidosis
Metabolic alkalosis
Respiratory alkalosis
Respiratory acidosis
The Correct Answer is B
A. Severe vomiting can lead to a loss of gastric acid, resulting in metabolic alkalosis and not acidosis.
B. A client who is experiencing severe nausea and vomiting may lose gastric acid through vomitus and develop metabolic alkalosis, which is a condition characterized by a high pH (greater than 7.45) and a high bicarbonate (greater than 26 mEq/L). Metabolic alkalosis can cause confusion, tremors, tetany, and hypokalemia.
C. Respiratory alkalosis is not typically associated with vomiting; it is more often seen in conditions with hyperventilation.
D. Respiratory acidosis is not the primary acid-base imbalance associated with vomiting; it is more commonly associated with conditions affecting lung function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While using fresher blood is desirable, it is not always practical, and the primary consideration is the client's clinical condition.
B. An 18-gauge needle may be used for rapid infusion, but the size of the needle should be appropriate for the client's condition and the facility's policy.
C. Monitoring vital signs is essential during a blood transfusion to detect any potential adverse reactions promptly.
D. Administering blood units over a recommended time frame is important, but obtaining vital signs at regular intervals during the transfusion is a more immediate and continuous monitoring method.
Correct Answer is C
Explanation
A. Bilateral flank pain is more indicative of a possible renal issue, not an allergic transfusion reaction.
B. Elevated blood pressure is not a typical sign of an allergic transfusion reaction.
C. Generalized urticaria (hives) is a classic manifestation of an allergic transfusion reaction.
D. Distended jugular veins are not typically associated with an allergic transfusion reaction.
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