A 45-year-old male presents to the emergency department after experiencing profuse vomiting and diarrhea for 3 days. His blood pressure is 90/60 mmHg, heart rate is 110 beats per minute, and mucous membranes are dry. Which of the following interventions should the nurse prioritize?
Encourage oral intake of water
Administer potassium-sparing diuretic
Restrict fluid intake
Administer IV bolus of normal saline
The Correct Answer is D
A. Encouraging oral intake may not be effective due to the patient's likely need for more rapid rehydration given his low blood pressure and heart rate.
B. A potassium-sparing diuretic is inappropriate in this situation, as the patient is already experiencing fluid loss and requires rehydration, not diuresis.
C. Restricting fluid intake would be contraindicated as the patient is in a state of dehydration and hypotension.
D. Administering an IV bolus of normal saline is the priority intervention to quickly restore fluid volume and improve blood pressure and hydration status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Binding is the initial step where the HIV virus attaches to the CD4 receptor on the host cell's surface. This interaction is crucial for the subsequent entry of the virus into the host cell.
B. Integration occurs later in the lifecycle, after the virus has entered the host cell and its RNA is converted to DNA.
C. Fusion refers to the process where the viral envelope fuses with the host cell membrane to allow entry into the cell, which follows the binding stage.
D. Reverse Transcription is the process of converting viral RNA into DNA after the virus has entered the host cell, and is not involved in the attachment phase.
Correct Answer is ["A","C"]
Explanation
A. Orthostatic hypotension is a common sign of hypovolemia, as the lack of fluid volume can lead to a drop in blood pressure when changing positions.
B. Bradycardia is not typically associated with fluid volume deficit; tachycardia is more common as the body tries to compensate for low blood volume.
C. Decreased skin turgor is a classic sign of dehydration and fluid volume deficit, indicating reduced skin elasticity.
D. Weight gain is associated with fluid volume overload, not deficit.
E. Pulmonary edema is related to fluid volume overload or congestive heart failure, not hypovolemia.
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