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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A) "You will be allowed to drive yourself home within 6 hours following the procedure."This statement is incorrect. After an esophagogastroduodenoscopy (EGD), the patient is typically sedated, and the sedation can affect their alertness, coordination, and judgment. It is generally recommended that patients arrange for someone else to drive them home. It is unsafe for the patient to drive themselves after sedation, even if they feel alert. The nurse should instruct the client to have someone accompany them to the procedure and drive them home afterward.

B) "You might experience a hoarse voice for several days following the procedure."This statement is correct. A hoarse voice is a common and expected side effect after an esophagogastroduodenoscopy, as the procedure involves passing a flexible tube (endoscope) through the mouth and throat. The endoscope may cause irritation to the vocal cords or the lining of the throat, leading to a hoarse voice that can last for a few days. This is a normal, transient effect and should be explained to the patient in advance so they are not alarmed.

C) "You can have a clear liquid diet for breakfast prior to the procedure."This statement is incorrect. For most procedures like EGD, patients are typically instructed to fast for at least 6 to 8 hours prior to the procedure to ensure the stomach is empty. Having food or liquids before the procedure may increase the risk of aspiration or interfere with the examination. The nurse should educate the client to follow fasting instructions and avoid consuming any food or liquids, including clear liquids, as per the healthcare provider's guidelines.

D) "You should not take any of your routine medications until after the procedure is complete."

This statement is generally incorrect. Many patients are instructed to continue taking routine medications, especially if they are vital for managing chronic conditions, unless otherwise directed by the healthcare provider. In some cases, medications such as anticoagulants, aspirin, or certain blood pressure medications may need to be withheld temporarily before the procedure. However, the nurse should clarify with the healthcare provider which medications the client should stop or continue taking before the procedure. The patient should not withhold medications on their own without proper guidance.

A. Multiple clots in the client's urinary bag B. Client reports bladder spasms when repositioning in bed C. Obstruction in client's urinary catheter continues after manual irrigation D. Client reports a pain rating of 3 on a 0 to 10 scale

Correct Answer is C

Explanation

A) Multiple clots in the client's urinary bag:
Multiple clots in the urinary bag can be expected after a transurethral resection of the prostate (TURP) as part of the normal postoperative bleeding. While clots can cause concern if they become excessive or obstructive, they are not as immediately critical as a persistent obstruction.

B) Client reports bladder spasms when repositioning in bed:
Bladder spasms are a common postoperative symptom following TURP and can be managed with antispasmodic medications and proper catheter care. Although uncomfortable, bladder spasms do not pose an immediate threat to the client’s health.

C) Obstruction in client's urinary catheter continues after manual irrigation:
A persistent obstruction in the urinary catheter after manual irrigation is a significant concern. This can indicate a severe blockage that might prevent urine from draining, leading to bladder distention, potential damage to the surgical site, and increased risk of infection. Immediate intervention is required to resolve the obstruction and ensure proper urinary drainage.

D) Client reports a pain rating of 3 on a 0 to 10 scale:
A pain rating of 3 on a 0 to 10 scale indicates mild pain, which is common in the postoperative period and can be managed with analgesics. While pain management is important, this level of pain does not constitute an urgent issue requiring immediate reporting to the provider.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is teaching a client who has peptic ulcer disease and is scheduled for an esophagogastroduodenoscopy the next morning. Which following information should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who is 4 hr postoperative following a transurethral resection of the prostate to treat benign prostatic hypertrophy. The client has an indwelling urinary catheter. Which of the following findings should the nurse report to the provider immediately?

Correct Answer is C

Explanation

A nurse is providing teaching to a group of expectant parents about risk factors for sudden Infant death syndrome. Which of the following risk factors should the nurse include?

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?

A nurse is teaching about nutrition to a client who has malabsorption syndrome due to inflammatory bowel disease. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is providing postoperative care for a client following a transurethral resection of the prostate to treat benign prostatic hypertrophy. Which of the following actions should the nurse take?

A nurse is examining a skin infection on a client's lower left leg. Findings include edema, erythema, tenderness, and the client reports pain. The nurse should identify that these findings indicate which of the following?

A nurse is discussing the five stages of grief by Kübler-Ross with a grief support group. Which of the following examples should the nurse identify as the first stage of the grief process?

A nurse is assessing a client who has hypocalcemia. Which of the following manifestations should the nurse expect?

A nurse is assessing a client who has left-sided heart failure with diminished cardiac output. Which of the following findings should the nurse expect?