An older client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea.
Vital Signs
Heart Rate-beats/minute- 110 Respirations - breathes/minute- 28 Blood Pressure – mmHG- 80/60
Arterial blood gases (ABGs)
Ph- 7.34
PaCO2- 34 mmHg
HCO3- 20 mmol/L
pO2- 90 mmHg
Electrolytes Results
Sodium
130 mEq/L(mmol/L) Potassium
2.5 mEq/L (mmol/L) Chloride
95 mEq/L (mmol/L)
Reference Range:
Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]
Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]
Chloride [98 to 106 mEq/L (98 to 106 mmol/L)]
PaCO2 [35 to 45 mm Hg]
HCO, [21 to 28 mEq/L (21 to 28 mmol/L)] PaO2 [80 to 100 mm Hg)
The nurse inserts a urinary catheter and obtains a scant amount of dark amber output. Which intervention should the nurse implement first? (Please scroll and view each tab's information in the client's medical record before selecting the answer.)
Initiate continuous dopamine infusion at 2 mcg/kg/minute.
Administer promethazine 25 mg slow intravenous (IV) push every 4 hours.
Begin potassium chloride 10 mEq over 1 hour per secondary infusion.
Give a bolus of 0.9% sodium chloride 1,000 ml over 30 minutes.
The Correct Answer is D
A) Incorrect - Initiating continuous dopamine infusion is not a priority in this situation. The client's low blood pressure and electrolyte imbalances require more immediate attention.
B) Incorrect - Administering promethazine addresses symptoms like nausea and vomiting, but it doesn't address the primary issue of hypovolemia and low blood pressure.
C) Incorrect - Administering potassium chloride without addressing the fluid deficit can be dangerous and may lead to further electrolyte imbalances.
D) Correct- The client's vital signs and laboratory results indicate hypovolemia (low blood pressure, low sodium, and low potassium). The immediate priority is to address the fluid deficit and correct the electrolyte imbalances. Administering a bolus of 0.9% sodium chloride (normal saline) will help increase intravascular volume and improve blood pressure, as well as correct the electrolyte imbalances to some extent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The client's statement of feeling worthless most days and having no interest in activities she previously enjoyed indicates a potential risk for self-directed violence, including self-harm or suicidal ideation. These signs are significant and require immediate attention and intervention by the nurse.
Assessing and addressing the client's risk for self-directed violence is of utmost importance to ensure her safety and well-being. The nurse should initiate a thorough assessment of the client's mental health, including assessing for any suicidal ideation, intent, or plans. It is crucial to establish a supportive and non-judgmental environment for the client to express her feelings and concerns.
The nurse should collaborate with the healthcare team to develop an appropriate care plan that may involve interventions such as close observation, involving a mental health professional, implementing safety measures, and providing emotional support.
While addressing other nursing problems, such as anxiety, imbalanced nutrition, and chronic low self-esteem, is important, the immediate concern is the client's risk for self-directed violence due to her feelings of hopelessness.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
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