A client presents to the emergency department complaining of several days of nausea and vomiting with weakness and dizziness. The client's vital signs are: Pulse 110, BP 88/56, RR 24, SpO2 95% on room air, temperature of 100.2. The client's lung sounds are clear bilaterally. Which of the following IV fluids would the nurse expect to administer?
Dextrose in water
6.45% Sodium Chloride
10% Dextrose in water
0.9% Sodium Chloride
The Correct Answer is D
A. Dextrose in water is typically used for hydration and to provide some calories. However, this client is presenting with hypotension (BP 88/56), tachycardia (Pulse 110), and weakness, likely due to fluid loss from vomiting. This client needs fluid resuscitation with a solution that will help restore circulating volume, and Dextrose in water does not contain sodium, which is necessary for fluid balance in this case.
B. 6.45% Sodium Chloride is a hypertonic saline solution, which would increase the osmolarity of the blood and pull fluid into the bloodstream. This would not be the first choice for this patient, as it could exacerbate dehydration and electrolyte imbalances.
C. 10% Dextrose in water is also a hypertonic solution that would provide energy but would not adequately address the client's fluid volume deficit or hypotension.
D. 0.9% Sodium Chloride is normal saline, which is an isotonic solution and is the most appropriate choice for fluid resuscitation in this client. It will help restore circulating blood volume, stabilize blood pressure, and provide the necessary hydration to address the client's symptoms of dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ensuring an incentive spirometer is available is important for postoperative care to prevent atelectasis, but it is not the priority immediately before surgery.
B. Preoperative teaching is valuable but should ideally be completed earlier in the care process. Last-minute teaching may overwhelm the patient or delay critical interventions.
C. Reporting allergies is essential, but if the allergy to sardines does not pertain to the current surgical plan or medications, it is not the immediate priority in this situation.
D. Administering the preoperative intravenous antibiotic is the top priority because it helps reduce the risk of surgical site infections. Timing of preoperative antibiotics is critical to their effectiveness.
Correct Answer is ["C","E"]
Explanation
A. Applying a constricting bandage/gauze wrap is contraindicated. This could further compromise circulation and exacerbate ischemia.
B. Advising the client about an immediate amputation is inappropriate and outside the nurse's scope of practice. The focus should be on timely intervention and notifying the surgeon.
C. Preparing the client to go back to the operating room is appropriate because the symptoms indicate potential compartment syndrome or vascular compromise, which often requires surgical intervention to restore circulation.
D. Elevating the extremity and applying ice is contraindicated in this scenario. Elevation can further decrease blood flow to an already ischemic limb, and ice application can cause vasoconstriction, worsening the issue.
E. Notifying the surgeon is essential. The described symptoms are a surgical emergency requiring immediate evaluation and intervention to prevent permanent damage.
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