The nurse should first address the client’s

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followed by the client’s

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.

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

Choice A rationale

Administering a suppository is considered a medication administration task, which requires a licensed nurse to perform. This task involves critical thinking and a solid understanding of anatomy, physiology, and pharmacology, as well as the potential for adverse reactions. Therefore, this cannot be delegated to an assistive personnel (AP), whose scope of practice does not include medication administration.

Choice B rationale

Providing home care instructions is part of client education, which is a key responsibility of a licensed nurse. This task requires a thorough understanding of the client's condition, treatment plan, and the ability to assess their learning needs. An AP is not trained to assess, plan, or implement teaching plans for clients, so this task is outside their scope of practice.

Choice C rationale

Suctioning a newly inserted tracheostomy is a skilled and invasive procedure that carries a high risk of complications, such as hypoxemia, trauma, or infection. This procedure requires a nurse's professional judgment and a clear understanding of sterile technique. The AP's role is to provide basic care, not to perform such complex and high-risk procedures.

Choice D rationale

Performing rescue breathing, or cardiopulmonary resuscitation (CPR), is an emergency procedure that falls within the scope of an AP's training. All healthcare workers, including APs, are required to have a basic life support certification. In a medical emergency, every staff member is expected to perform basic life-saving measures, such as rescue breathing, to prevent further client harm. *.