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 C

Explanation

A) Hiccups: Hiccups are not a common adverse effect of lisinopril. While they can be bothersome, they are not typically associated with this medication. Monitoring for more significant side effects is crucial, but hiccups alone are not usually indicative of a serious reaction.

B) Anxiousness: Anxiousness or anxiety is not a typical side effect of lisinopril. While anxiety can occur due to various factors, it is not directly linked to the use of lisinopril. The focus should be on more specific adverse effects related to the medication.

C) Cough: A persistent, dry cough is a well-documented adverse effect of lisinopril. Angiotensin-converting enzyme (ACE) inhibitors like lisinopril can cause a cough due to the accumulation of bradykinin. This side effect is significant and often leads to discontinuation of the medication.

D) Rhinorrhea: Rhinorrhea, or a runny nose, is not a common adverse effect of lisinopril. Although it can occur with other conditions or medications, it is not specifically associated with ACE inhibitors. Monitoring for more characteristic side effects of lisinopril is important.

A. Reports intolerance to heat B. Develops bradycardia after eating C. Has a friction rub on auscultation D. Displays dyspnea while walking

Correct Answer is D

Explanation

A) Reports intolerance to heat: Intolerance to heat is more commonly associated with conditions like hyperthyroidism rather than iron-deficiency anemia. Individuals with iron-deficiency anemia often experience fatigue and cold intolerance due to decreased oxygen-carrying capacity of the blood.

B) Develops bradycardia after eating: Bradycardia (slow heart rate) is not typically associated with iron-deficiency anemia. Anemia usually causes an increased heart rate (tachycardia) as the body tries to compensate for reduced oxygen delivery.

C) Has a friction rub on auscultation: A friction rub is a sound heard on auscultation associated with pericarditis, an inflammation of the pericardium, and is not a typical finding in iron-deficiency anemia. Anemia primarily affects the blood and does not usually cause inflammation of the heart lining.

D) Displays dyspnea while walking: Dyspnea, or shortness of breath, is a common symptom of iron-deficiency anemia, particularly with exertion. This occurs because the reduced hemoglobin levels result in decreased oxygen delivery to tissues, making physical activities more challenging and causing breathlessness.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hypertension and is taking lisinopril. The nurse should monitor the client for which of the following findings as an adverse effect of lisinopril?

Correct Answer is C

Explanation

A nurse is assessing a client who has iron-deficiency anemia. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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