A nurse is assessing a client who is experiencing profuse vomiting.
Upon admission, the client's vital signs were within the expected reference range, but now the client's blood pressure is 86/58 mm Hg, his pulse is 114/min and weak, and his respiratory rate is 27/min.
The client appears restless and anxious and states that he thinks he is dying.
Which of the following actions should the nurse take first?
Administer a vasoconstrictor.
Increase the IV infusion rate.
Elevate the client's feet.
Initiate oxygen therapy.
The Correct Answer is B
Choice A rationale
Administering a vasoconstrictor is a potential intervention for shock but it is not the first action. The client's hypotension and tachycardia are indicative of hypovolemic shock due to profuse vomiting, leading to fluid loss. The body's initial compensatory mechanism involves vasoconstriction to maintain blood pressure, so further constriction without addressing the volume deficit can worsen tissue perfusion.
Choice B rationale
The client is exhibiting signs of hypovolemic shock, including a low blood pressure of 86/58 mmHg, a high pulse of 114/min, and a high respiratory rate of 27/min. These are physiological compensations for reduced circulating blood volume. Increasing the intravenous infusion rate directly addresses the primary problem by rapidly replacing lost fluid volume, thereby increasing preload, stroke volume, cardiac output, and ultimately, blood pressure.
Choice C rationale
Elevating the client's feet can temporarily increase venous return to the heart and improve blood pressure. However, this is a passive measure that does not address the underlying fluid deficit causing the hypovolemic shock. It is a helpful adjunctive action but is not the definitive first-line intervention required to correct the circulatory collapse in this scenario.
Choice D rationale
Initiating oxygen therapy is a supportive measure for shock because it helps improve tissue oxygenation, which is compromised due to poor perfusion. While beneficial, it does not correct the root cause of the shock, which is the lack of circulating fluid volume. The most immediate and life-saving intervention is to restore fluid volume to improve cardiac output and blood pressure
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Increasing the rate of formula delivery would worsen hyperosmolar dehydration. A faster rate delivers more solute-rich formula to the gastrointestinal tract in a shorter time, pulling more free water from the body's vascular space into the gut lumen via osmosis. This fluid shift further depletes the body's free water, intensifying the dehydration and increasing serum osmolality.
Choice B rationale
Hyperosmolar dehydration occurs when the body's free water is drawn into the gastrointestinal tract due to a high solute concentration in the enteral formula. By adding free water to the formula, the nurse dilutes the solution, lowering its osmolarity. This action helps to balance the osmotic gradient, reducing the fluid shift and preventing further dehydration.
Choice C rationale
Switching to a lactose-free formula is indicated for clients with lactose intolerance, which causes symptoms like diarrhea and bloating, but it does not directly address hyperosmolar dehydration. Hyperosmolar dehydration is related to the overall solute load and concentration of the formula, not specifically the presence or absence of lactose.
Choice D rationale
Repositioning the NG tube is an action to ensure proper placement and prevent complications like aspiration, but it does not resolve hyperosmolar dehydration. This type of dehydration is a systemic problem related to fluid and electrolyte balance, not a local issue with the tube's position within the gastrointestinal tract. *.
Correct Answer is A
Explanation
Choice A rationale
Chills are a systemic manifestation of an infectious process and are commonly associated with endometritis. Endometritis is an infection of the uterine lining, which can cause a systemic inflammatory response. This response often includes fever and chills, as the body's immune system fights the invading pathogens, causing a thermoregulatory cascade. A temperature of 100.4°F (38°C) or higher is typical.
Choice B rationale
Back pain can occur with various postpartum conditions, but it is not a primary or specific finding for endometritis. While uterine cramping and pelvic pain are characteristic due to the uterine inflammation, back pain is not as specific. More classic signs are fever, lower abdominal pain, uterine tenderness, and foul-smelling lochia due to the presence of bacteria.
Choice C rationale
Tachycardia, not bradycardia, is an expected finding in a client with endometritis. Tachycardia is a physiological response to fever, infection, and the systemic inflammatory process. The heart rate increases to compensate for increased metabolic demand and to circulate immune cells more efficiently. Bradycardia would be an unusual and unexpected finding.
Choice D rationale
Agitation is not a primary or typical finding of endometritis. Endometritis is a physical infection of the uterine lining. While discomfort and fever may cause irritability, agitation is not a specific expected symptom. This finding is more associated with neurological or psychiatric conditions, or severe complications like septic shock, which is a more advanced state. *.
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