A 45-year-old male presents to the emergency department after experiencing profuse vomiting and diarrhea for 3 days. His blood pressure is 90/60 mmHg, heart rate is 110 beats per minute, and mucous membranes are dry. Which of the following interventions should the nurse prioritize?
Encourage oral intake of water
Administer potassium-sparing diuretic
Restrict fluid intake
Administer IV bolus of normal saline
The Correct Answer is D
A. Encouraging oral intake may not be effective due to the patient's likely need for more rapid rehydration given his low blood pressure and heart rate.
B. A potassium-sparing diuretic is inappropriate in this situation, as the patient is already experiencing fluid loss and requires rehydration, not diuresis.
C. Restricting fluid intake would be contraindicated as the patient is in a state of dehydration and hypotension.
D. Administering an IV bolus of normal saline is the priority intervention to quickly restore fluid volume and improve blood pressure and hydration status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Muscle weakness and confusion are more commonly associated with metabolic or mixed acid-base disturbances rather than respiratory alkalosis specifically.
B. Decreased deep tendon reflexes and hypotension are not typical signs of respiratory alkalosis, which usually involves changes in breathing patterns.
C. Bradycardia and decreased respiratory rate are more likely associated with respiratory acidosis or other conditions, not with respiratory alkalosis.
D. Rapid, shallow breathing, often due to anxiety or panic attacks, is characteristic of respiratory alkalosis. Patients may also report feelings of panic due to the hyperventilation that leads to this condition.
Correct Answer is A
Explanation
A. Respiratory acidosis is indicated by the low pH (7.22) and elevated PaCO2 (68 mm Hg), demonstrating that CO2 is retained due to hypoventilation (as seen with a respiratory rate of 7/min). The bicarbonate level is within normal range, suggesting no metabolic compensation is present.
B. Metabolic acidosis would be indicated by a low pH and low bicarbonate level, which is not the case here since the bicarbonate is normal at 26 mEq/L.
C. Metabolic alkalosis would present with a high pH and high HCO3, which does not match these values.
D. Respiratory alkalosis would show a high pH and low PaCO2, which is contrary to the provided ABG results.
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