A nurse in an emergency department is assessing a client who was biten on the left leg by a poisonous snake. The client has placed elastic bandages snugly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take?

Choice A Reason: This is incorrect because these values indicate respiratory alkalosis, which is caused by hyperventilation or excess loss of carbon dioxide (PaCO2). Respiratory alkalosis increases the blood pH and decreases the HCO3- level.

Choice B Reason: This is incorrect because these values indicate metabolic alkalosis, which is caused by excess intake or retention of bases or loss of acids. Metabolic alkalosis increases the blood pH and the HCO3- level.

Choice C Reason: This is incorrect because these values indicate respiratory acidosis, which is caused by hypoventilation or excess retention of carbon dioxide (PaCO2). Respiratory acidosis decreases the blood pH and increases the HCO3- level.

Choice D Reason: This is correct because these values indicate metabolic acidosis, which is a common complication of chronic kidney disease. These values indicate metabolic acidosis, which is a common complication of chronic kidney disease. Metabolic acidosis occurs when the kidneys are unable to excrete excess acids or retain enough bicarbonate (HCO3-), which is a base that buffers the blood pH. As a result, the blood pH decreases and becomes more acidic. The normal range for blood pH is 7.35 to 7.45, for HCO3- is 22 to 26 mEq/L, and for PaCO2 is 35 to 45 mm Hg.

The correct answer is: C. Continue the rate at 125 mL/hr.
Choice A: Slow the rate to 50 mL/hr
Slowing the IV fluid rate to 50 mL/hr is not appropriate for a patient with a head injury. Adequate fluid management is crucial to maintain cerebral perfusion pressure and prevent secondary brain injury. Reducing the rate to 50 mL/hr could lead to hypovolemia, which might decrease cerebral perfusion and worsen the patient’s condition.
Choice B: Slow the rate to 20 mL/hr
Slowing the IV fluid rate to 20 mL/hr is even less appropriate. Such a low rate would likely result in significant hypovolemia, severely compromising cerebral perfusion pressure. This could exacerbate the patient’s head injury by reducing the blood flow to the brain, leading to further damage.
Choice C: Continue the rate at 125 mL/hr
Continuing the rate at 125 mL/hr is appropriate. This rate helps maintain euvolemia, which is essential for ensuring adequate cerebral perfusion pressure in patients with head injuries. Maintaining a stable fluid rate helps prevent both hypovolemia and hypervolemia, both of which can negatively impact intracranial pressure and cerebral perfusion.
Choice D: Increase the rate to 250 mL/hr
Increasing the IV fluid rate to 250 mL/hr is not recommended. Overhydration can lead to increased intracranial pressure, which can be detrimental to a patient with a head injury. Excessive fluid administration can cause cerebral edema, worsening the patient’s condition.