A nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500 mL of blood. Which of the following actions is the nurse’s priority?

Elevate the client’s feet.

Administer a unit of packed RBCs.

Initiate a dopamine IV infusion for the client.

Increase the client’s IV ﬂuid rate.

Answer and Explanation

The Correct Answer is D

Choice a) is incorrect because elevating the client’s feet is not the priority action for a hypotensive client. Elevating the client’s feet may help increase the venous return to the heart, but it may also compromise the respiratory status of a client who has esophageal varices and is at risk of aspiration.

Choice b) is incorrect because administering a unit of packed RBCs is not the priority action for a hypotensive client. Administering a unit of packed RBCs may help increase the oxygen-carrying capacity of the blood, but it may also increase the blood viscosity and pressure, which can worsen the bleeding from the esophageal varices.

Choice c) is incorrect because initiating a dopamine IV infusion for the client is not the priority action for a hypotensive client. Initiating a dopamine IV infusion may help increase the blood pressure and cardiac output, but it may also cause vasoconstriction and tachycardia, which can increase the risk of hemorrhage and arrhythmias.

Choice d) is correct because increasing the client’s IV ﬂuid rate is the priority action for a hypotensive client. Increasing the client’s IV ﬂuid rate may help restore the intravascular volume and perfusion, which can prevent shock and organ damage. Increasing the client’s IV ﬂuid rate may also dilute the blood and reduce its viscosity and pressure, which can decrease the bleeding from the esophageal varices.

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Correct Answer is C

Explanation

Choice A Reason: This is incorrect. Sinus bradycardia is a slow and regular heart rate that originates from the sinus node. It does not cause irregular palpitations, fatigue, or dizziness, unless the heart rate is very low or the client has underlying cardiac disease.

Choice B reason: This is incorrect. Sinus tachycardia is a fast and regular heart rate that originates from the sinus node. It may cause fatigue or dizziness, but not irregular palpitations or pulse deficit.

Choice C Reason: This is correct. Atrial fibrillation is a fast and irregular heart rate that originates from multiple foci in the atria. It causes irregular palpitations, fatigue, dizziness, and pulse deficit due to ineﬀective atrial contractions and variable ventricular response.

Choice D Reason: This is incorrect. First-degree AV block is a delay in the conduction of impulses from the atria to the ventricles. It does not aﬀect the heart rate or rhythm, and does not cause any symptoms.

A. Fatigue B. Dyspnea C. Oliguria D. Pitting edema

Correct Answer is A

Explanation

Choice A: Fatigue is a manifestation that the nurse should identify as indicating the client is hypokalemic. Hypokalemia is a condition in which the blood potassium level is lower than normal, usually due to excessive loss of potassium through urine, sweat, or vomiting. Potassium is an electrolyte that is essential for nerve and muscle function, especially for the heart. Hypokalemia can cause muscle weakness, cramps, and fatigue, as well as cardiac arrhythmias and dysrhythmias.

Choice B: Dyspnea is not a manifestation that the nurse should identify as indicating the client is hypokalemic. Dyspnea is a sensation of difficulty breathing or shortness of breath. Dyspnea can be caused by various conditions, such as asthma, chronic obstructive pulmonary disease (COPD), pneumonia, or pulmonary edema. Dyspnea is not directly related to hypokalemia, but it can be a sign of heart failure, which can cause ﬂuid accumulation in the lungs and impair gas exchange.

Choice C: Oliguria is not a manifestation that the nurse should identify as indicating the client is hypokalemic. Oliguria is a reduced urine output, usually less than 400 mL per day or 30 mL per hour. Oliguria can be caused by various conditions, such as dehydration, kidney failure, urinary tract obstruction, or shock. Oliguria is not directly related to hypokalemia, but it can be a sign of kidney damage or impairment, which can aﬀect electrolyte balance and ﬂuid volume.

Choice D: Pitting edema is not a manifestation that the nurse should identify as indicating the client is hypokalemic. Pitting edema is a swelling of the tissues that leaves an indentation when pressed with a finger. Pitting edema can be caused by various conditions, such as venous insufficiency, lymphedema, liver cirrhosis, or malnutrition. Pitting edema is not directly related to hypokalemia, but it can be a sign of heart failure, which can cause ﬂuid retention and overload in the body.

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