A nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500 mL of blood. Which of the following actions is the nurse’s priority?
Elevate the client’s feet.
Administer a unit of packed RBCs.
Initiate a dopamine IV infusion for the client.
Increase the client’s IV fluid rate.
The Correct Answer is D
Choice a) is incorrect because elevating the client’s feet is not the priority action for a hypotensive client. Elevating the client’s feet may help increase the venous return to the heart, but it may also compromise the respiratory status of a client who has esophageal varices and is at risk of aspiration.
Choice b) is incorrect because administering a unit of packed RBCs is not the priority action for a hypotensive client. Administering a unit of packed RBCs may help increase the oxygen-carrying capacity of the blood, but it may also increase the blood viscosity and pressure, which can worsen the bleeding from the esophageal varices.
Choice c) is incorrect because initiating a dopamine IV infusion for the client is not the priority action for a hypotensive client. Initiating a dopamine IV infusion may help increase the blood pressure and cardiac output, but it may also cause vasoconstriction and tachycardia, which can increase the risk of hemorrhage and arrhythmias.
Choice d) is correct because increasing the client’s IV fluid rate is the priority action for a hypotensive client. Increasing the client’s IV fluid rate may help restore the intravascular volume and perfusion, which can prevent shock and organ damage. Increasing the client’s IV fluid rate may also dilute the blood and reduce its viscosity and pressure, which can decrease the bleeding from the esophageal varices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Hct 45% is not a value that the nurse should report to the provider. Hct, or hematocrit, is the percentage of red blood cells in the total blood volume. The normal range for Hct is 37% to 51% for men and 32% to 45% for women. Hct 45% is within the normal range and does not indicate any abnormality.
Choice B: Platelets 160,000/mm³ is not a value that the nurse should report to the provider. Platelets, or thrombocytes, are cell fragments that help with blood clotting and hemostasis. The normal range for platelets is 150,000 to 450,000/mm³. Platelets 160,000/mm³ is within the normal range and does not indicate any abnormality.
Choice C: WBC 1,700/mm³ is a value that the nurse should report to the provider. WBC, or white blood cells, are cells that fight infection and inflammation. The normal range for WBC is 4,500 to 11,000/mm³. WBC 1,700/mm³ is below the normal range and indicates leukopenia, which is a low number of white blood cells. Leukopenia can be caused by various conditions, such as viral infections, autoimmune disorders, bone marrow suppression, or chemotherapy. Leukopenia can increase the risk of infection and sepsis and requires prompt evaluation and treatment.
Choice D: Hgb 14.7 g/dL is not a value that the nurse should report to the provider. Hgb, or hemoglobin, is a protein in red blood cells that carries oxygen to the tissues. The normal range for Hgb is 13.5 to 17.5 g/dL for men and 12.0 to 15.5 g/dL for women. Hgb 14.7 g/dL is within the normal range and does not indicate any abnormality.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because the client's best motor response is 5, which means he can localize pain, not follow commands.
Choice B Reason: This is incorrect because the client's eye opening response is 3, which means he opens his eyes to pain, not to speech.
Choice C Reason: This is correct because the client's GCS score is 13, which indicates a severe impairment of consciousness. The GCS is a tool used to assess the level of consciousness of a person who has a head injury. The GCS score ranges from 3 to 15, with lower scores indicating lower levels of consciousness. A GCS score of 8 or less indicates coma. The client's GCS score is 3 + 5 + 5 = 13, which is above the coma threshold, but still indicates a severe impairment of consciousness. The other choices are not consistent with the client's GCS score.
Choice D Reason: This is incorrect because the client's best verbal response is 5, which means he can orient himself to person, place, and time, not that he is unable to make vocal sounds.
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