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 D
Explanation
Choice A rationale
Amnioinfusion is the infusion of saline into the amniotic cavity. It is used to treat umbilical cord compression or meconium staining, not to manage seizures. Initiating an amnioinfusion during a seizure would be an inappropriate and ineffective intervention that would not address the underlying physiological cause of eclampsia or the immediate post-seizure recovery.
Choice B rationale
An internal fetal heart monitor is an invasive procedure requiring the rupture of membranes and insertion of a fetal spiral electrode. This is not the priority action following a seizure. Post-seizure priority is maternal stabilization, ensuring a patent airway, and preventing further injury. External fetal monitoring is the standard first-line approach to assess fetal well-being.
Choice C rationale
Calcium gluconate is the antidote for magnesium sulfate toxicity, not a treatment for seizures. Administering calcium gluconate would be inappropriate unless magnesium toxicity (e.g., respiratory depression) is suspected. The primary treatment for eclamptic seizures is magnesium sulfate, which works by depressing the central nervous system and blocking neuromuscular conduction.
Choice D rationale
Placing the client on her side is the priority action following a seizure. This position prevents aspiration of secretions, promotes venous return to the heart, and improves placental perfusion. This is a critical safety measure to protect both the mother and the fetus from further harm and is part of standard post-ictal care. *.
Correct Answer is A
Explanation
Choice A rationale
The herpes zoster vaccine, also known as the shingles vaccine, is specifically recommended for older adults. The incidence and severity of shingles, which is caused by the reactivation of the varicella-zoster virus, increase significantly with age, particularly after 50 years. The vaccine works by boosting the immune response to the virus, thereby reducing the risk of developing shingles and the associated long-term neuropathic pain.
Choice B rationale
The human papillomavirus (HPV) vaccine is recommended for individuals up to age 26, with a primary target age of 11 or 12. It is not typically recommended for older adults because most have already been exposed to the virus, and the vaccine is most effective before sexual activity begins. The immune response in older adults is also less robust than in younger individuals, making the vaccine less effective in this population.
Choice C rationale
The rotavirus vaccine is recommended for infants and young children, usually in a series of doses starting at 2 months of age. Rotavirus is a common cause of severe diarrhea in infants and young children, but it does not pose a significant health threat to older adults. The vaccine is not indicated for older adults because they have usually developed immunity from previous exposures to the virus.
Choice D rationale
Diphtheria, tetanus, and acellular pertussis (DTaP) vaccine is primarily given to infants and young children in a series of doses. For older adults, the Tdap or Td booster is recommended. The Tdap vaccine provides protection against tetanus, diphtheria, and pertussis, which is important for older adults as their immunity wanes over time. However, the DTaP formulation is not the one typically recommended for this age group. .
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.