A nurse is assessing a client who is experiencing profuse vomiting.
Upon admission, the client's vital signs were within the expected reference range, but now the client's blood pressure is 86/58 mm Hg, his pulse is 114/min and weak, and his respiratory rate is 27/min.
The client appears restless and anxious and states that he thinks he is dying.
Which of the following actions should the nurse take first?
Administer a vasoconstrictor.
Increase the IV infusion rate.
Elevate the client's feet.
Initiate oxygen therapy.
The Correct Answer is B
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A sliding hiatal hernia occurs when the gastroesophageal junction and a portion of the stomach slide up into the chest through the diaphragm's esophageal hiatus. This displacement disrupts the lower esophageal sphincter's function, causing gastric acid to reflux into the esophagus and resulting in heartburn.
Choice B rationale
Abdominal cramping is typically associated with conditions affecting the intestines, such as irritable bowel syndrome, inflammatory bowel disease, or bowel obstruction. It is not a direct symptom of a sliding hiatal hernia, which primarily affects the stomach and esophagus.
Choice C rationale
Breathlessness or dyspnea can be a symptom of a very large hiatal hernia that compresses the lungs. However, for a standard sliding hiatal hernia, it is not a primary or expected finding. The most common manifestation is related to acid reflux.
Choice D rationale
Constipation is a condition of the large intestine and is characterized by infrequent bowel movements. It is not directly caused by a sliding hiatal hernia, as the hernia’s primary impact is on the stomach and esophagus, causing upper gastrointestinal symptoms. *.
Correct Answer is B
Explanation
Choice A rationale
Tomato soup is highly acidic due to its tomato base, which can relax the lower esophageal sphincter (LES) and increase stomach acid production. This can lead to the reflux of gastric contents into the esophagus, exacerbating the symptoms of GERD. The client should avoid highly acidic foods to manage their condition effectively.
Choice B rationale
White fish is a lean protein that is generally low in fat. High-fat foods can delay stomach emptying and decrease the pressure of the lower esophageal sphincter, increasing the risk of acid reflux. Lean proteins like white fish are less likely to trigger symptoms and are therefore a suitable dietary choice for a client with GERD.
Choice C rationale
Hot cocoa contains both caffeine and fat, which are known to exacerbate GERD symptoms. Caffeine can relax the lower esophageal sphincter, allowing stomach acid to reflux. Additionally, the fat content can delay gastric emptying, increasing pressure on the LES and worsening acid reflux symptoms.
Choice D rationale
Decaffeinated coffee can still trigger GERD symptoms. Coffee, even without caffeine, is acidic and can stimulate the production of stomach acid. The oils and compounds in coffee can also relax the lower esophageal sphincter, increasing the likelihood of acid reflux and causing irritation to the esophageal lining.
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