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. The new diagnosis of COPD with supplemental oxygen suggests a chronic but not necessarily terminal condition.
B. Stage IV breast cancer with an expected survival of 3 months is an indication for hospice care.
C. Terminal lung cancer with discontinued treatment is an appropriate scenario for hospice care.
D. End-stage kidney disease with stopped dialysis is an indication for hospice care.
Correct Answer is B
Explanation
A. While cold packs might be used for certain conditions, measuring the circumference of both upper arms is the priority in this situation.
B. Swelling of the arm above the PICC insertion site can indicate a complication such as thrombophlebitis, which is inflammation and clotting of the vein. The nurse should measure the circumference of both upper arms and compare them to detect any difference in size, which can indicate edema due to impaired venous return. This is the first action the nurse should take because it is an assessment step that can provide objective data to guide further interventions.
C. Swelling above the PICC insertion site could indicate complications such as infiltration, and the provider needs to be informed promptly. However, the nurse should first measure the circumference of both upper arms first.
D. Removing the PICC line should be done under the guidance of a healthcare provider, and it is not the first action to take.
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