A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.).
Lethargy.
Kussmaul's respirations.
Circumoral paresthesia.
Bicarbonate excess.
Flushing
Correct Answer : A,C,D
The correct answer is choice A, C, and D.
Choice A rationale:
Lethargy is a common symptom of metabolic alkalosis due to the body’s attempt to compensate for the altered pH balance, leading to decreased energy levels and fatigue.
Choice B rationale:
Kussmaul’s respirations are typically associated with metabolic acidosis, not alkalosis. These deep, labored breaths are the body’s way of trying to expel excess carbon dioxide to correct acidosis.
Choice C rationale:
Circumoral paresthesia, or tingling around the mouth, is a symptom of metabolic alkalosis. This occurs due to changes in calcium ion concentration affecting nerve function.
Choice D rationale:
Bicarbonate excess is a direct cause of metabolic alkalosis. Elevated bicarbonate levels in the blood lead to an increased pH, resulting in alkalosis.
Choice E rationale:
Flushing is not a typical symptom of metabolic alkalosis. It is more commonly associated with conditions that cause vasodilation or increased blood flow to the skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Other electrolyte disturbances.
Choice A rationale:
Drug toxicity is not directly related to hypocalcemia. The main concern in hypocalcemia is the calcium imbalance itself, not drug toxicity.
Choice B rationale:
Other electrolyte disturbances should be assessed because imbalances in other electrolytes, such as potassium and magnesium, are often associated with hypocalcemia. Electrolyte imbalances can interact and exacerbate each other, potentially leading to more severe complications.
Choice C rationale:
Hypertension is not a typical assessment finding in hypocalcemia. Hypertension is not directly related to calcium levels but may have other underlying causes.
Choice D rationale:
Visual disturbances are not commonly associated with hypocalcemia. Hypocalcemia is more likely to present with neuromuscular and cardiovascular symptoms, rather than visual disturbances.
Correct Answer is ["C","D","E"]
Explanation
The correct answer is choiceC. Monitor the injection site for redness,D. Use an infusion controller for the IV, andE. Monitor fluid intake and output.
Choice A rationale:
Adding the ordered dose to the IV hanging is incorrect because potassium chloride should never be added to an already hanging IV solution due to the risk of uneven distribution and potential overdose.
Choice B rationale:
Administering the dose IV push over 3 minutes is incorrect because potassium chloride should never be given by direct IV injection.It must always be diluted and administered slowly to prevent cardiac complications.
Choice C rationale:
Monitoring the injection site for redness is correct because potassium chloride can cause irritation and phlebitis at the injection site.
Choice D rationale:
Using an infusion controller for the IV is correct because it ensures the potassium chloride is administered at a controlled rate, reducing the risk of rapid infusion and potential cardiac issues.
Choice E rationale:
Monitoring fluid intake and output is correct because it helps assess the patient’s overall fluid balance and detect any signs of fluid overload or deficit, which is crucial when administering potassium.
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