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 A

Explanation

A) A client refuses to discuss treatment options with her provider following a terminal diagnosis: This behavior exemplifies denial, the first stage in Kübler-Ross's five stages of grief. In this stage, individuals are unable to accept the reality of their situation, often refusing to acknowledge the facts and avoiding discussions that might confirm the severity of their condition.

B) A client promises a higher power to live a better life if his cancer is healed: This illustrates the bargaining stage, where individuals attempt to negotiate or make deals with a higher power or fate to reverse or delay the loss or illness. They hope that by promising to change their behavior, they can influence the outcome.

C) A client withdraws from his social network following the death of a loved one: Withdrawal from social interactions is indicative of the depression stage, where individuals may feel profound sadness, hopelessness, and a desire to isolate themselves as they process the magnitude of their loss.

D) A client yells at healthcare staff following the death of a loved one: This behavior is characteristic of the anger stage, where individuals express their frustration and helplessness through anger, often directed at people around them, including healthcare providers. This stage reflects the struggle to find meaning and control in the face of loss.

A. Keep client in semi-Fowler's position with right extremity flat. B. Manage pain with oral opioids every 6 hr. C. Check capillary refill hourly for the first 24 hr. D. Apply a compression dressing over the fracture site.

Correct Answer is D

Explanation

A) Keep client in semi-Fowler's position with right extremity flat: Keeping the client in a semi-Fowler's position with the extremity flat is not appropriate for managing a compound fracture. Elevating the affected limb, if possible, helps reduce swelling and pain, but the position should also consider overall stability and comfort.

B) Manage pain with oral opioids every 6 hr: Oral opioids are not the best choice for immediate pain management in an emergency setting, especially with a compound fracture. Intravenous pain medications are typically more effective for acute, severe pain in such situations and can provide quicker relief.

C) Check capillary refill hourly for the first 24 hr: Checking capillary refill is important to assess blood flow and perfusion, but hourly checks for 24 hours may not be necessary and can be overly frequent unless specific concerns arise. Monitoring should be based on clinical judgment and the client's condition.

D) Apply a compression dressing over the fracture site: Applying a compression dressing over the fracture site can help control bleeding and stabilize the area. Compound fractures involve an open wound, so controlling bleeding while minimizing the risk of infection is crucial. This intervention is essential in managing the initial trauma before more definitive surgical treatment.

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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

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Explanation

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