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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Hypokalemia is not a direct adverse effect of dextrose 10% in water infusion. This solution does not contain potassium, and unless the patient already has low potassium levels or other contributing factors, it would not cause hypokalemia.
Choice B rationale:
Hypercalcemia is unrelated to dextrose 10% in water infusion. The solution does not contain calcium, and it would not lead to an increase in serum calcium levels.
Choice C rationale:
Hypovolemia, or low blood volume, is not typically associated with dextrose 10% in water infusion. However, if administered rapidly in large amounts, it could potentially cause fluid overload leading to hypervolemia.
Choice D rationale:
Hyperglycemia is a possible adverse effect of dextrose 10% in water infusion. The solution contains a high concentration of glucose, which can raise blood sugar levels if the body cannot adequately utilize or regulate the glucose. Regular monitoring of blood glucose levels is essential during such an infusion, especially in patients with diabetes or impaired glucose tolerance.
Correct Answer is D
Explanation
The correct answer isd. Assess for indications of pulmonary embolism.
Choice A rationale:
Administering a sedative is not appropriate as the priority intervention. Sedatives can depress respiratory function, which is already compromised in this patient.
Choice B rationale:
Preparing for mechanical ventilation might be necessary if the patient’s condition worsens, but it is not the immediate priority. The priority is to identify the underlying cause of the symptoms.
Choice C rationale:
Massaging the calf area for tenderness is not relevant in this context. While calf tenderness can be a sign of deep vein thrombosis (DVT), which can lead to pulmonary embolism, the immediate priority is to assess for pulmonary embolism directly.
Choice D rationale:
Assessing for indications of pulmonary embolism is the priority because the patient’s symptoms (shortness of breath, chest pain, recent use of birth control pills, smoking history, and abnormal ABG values) strongly suggest a pulmonary embolism.Early identification and treatment are crucial to prevent further complications.
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