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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Metabolic alkalosis is characterized by an increased pH and increased HCO3 levels, which does not fit the provided values.
B. The low HCO3 of 18 mEq indicates a metabolic acidosis, as the body is unable to retain enough bicarbonate to balance the acid levels, and the pH is also low at 7.30, confirming acidosis.
C. Respiratory alkalosis would show a high pH and low PaCO2, which is not the case here.
D. Respiratory acidosis would be indicated by a high PaCO2 and a low pH, but the HCO3 level is low, indicating a metabolic issue rather than a respiratory one.

A. Assess the client's airway. B. Call the emergency response team. C. Apply high-flow oxygen. D. Initiate IV access. E. Administer IV epinephrine. F. Administer IV antihistamines.

Correct Answer is A,B,C,D,E,F

Explanation

1. Assessing the client's airway is the priority to determine if there is any obstruction or compromise due to swelling.

2. Calling the emergency response team ensures that additional medical help is on the way if the situation worsens.

3. Applying high-flow oxygen is critical to address potential hypoxia from airway swelling.

4. Initiating IV access is necessary for administering medications.

5. Administering IV epinephrine is essential to counteract severe allergic reactions, such as angioedema.

6. Administering IV antihistamines can help alleviate symptoms but is secondary to the immediate interventions for airway management and epinephrine administration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has the following arterial blood gas results: HCO3 18 mEq, PaCO2 28 mm Hg, and pH 7.30. The nurse recognizes the client is experiencing which of the following acid-base imbalances?

Correct Answer is B

Explanation

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Correct Answer is A,B,C,D,E,F

Explanation

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