A patient presents with a heart rate of 130 beats/minute and a blood pressure of 82/66 after exerting themselves in the sun. Which of the following interventions would be most appropriate?
Administer a hypotonic solution
Administer a vasoconstrictor medication
Administer an isotonic solution intravenously
Administer a hypertonic solution intravenously
The Correct Answer is C
A. Administering a hypotonic solution would not be appropriate in this case. Hypotonic solutions can lower the blood pressure further and worsen the patient’s condition.
B. Administering a vasoconstrictor medication may increase blood pressure, but it is not the first-line treatment for dehydration or volume loss, which seems to be the cause of the patient’s symptoms.
C. Administering an isotonic solution intravenously is the most appropriate intervention. The patient is likely experiencing dehydration and hypotension due to fluid loss from exertion in the sun (possibly heat exhaustion). Isotonic fluids such as normal saline or lactated Ringer's solution are typically used to restore circulating volume and improve blood pressure.
D. Administering a hypertonic solution would be inappropriate, as it could increase the osmolarity of the blood and worsen dehydration, potentially causing fluid shifts that could lead to complications such as cellular dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While impaired perineal skin integrity is a concern due to frequent diarrhea, it is not the priority because it does not pose an immediate threat to the client’s overall health or survival.
B. Protein-calorie malnutrition is a long-term risk associated with Crohn’s disease but is less critical during an acute exacerbation compared to immediate risks like fluid and electrolyte imbalance.
C. Although pain related to abdominal cramping is a significant concern, addressing pain does not take precedence over life-threatening risks such as dehydration or electrolyte disturbances.
D. Fluid and electrolyte imbalance is the priority because severe diarrhea can rapidly lead to dehydration, hypovolemia, and electrolyte imbalances, which can cause life-threatening complications such as cardiac arrhythmias or shock.
Correct Answer is ["B","D","E"]
Explanation
A. Intact motor function is not a sign of compartment syndrome. Motor deficits, rather than intact function, would raise concern for this condition.
B. A capillary refill time of 5 seconds is prolonged and indicates impaired circulation, which is a sign of compartment syndrome.
C. A bounding pulse is not consistent with compartment syndrome. Pulses may initially remain normal but can diminish as the condition progresses.
D. Pallor to the lower extremity suggests compromised blood flow, which is a hallmark of compartment syndrome.
E. Numbness and tingling (paresthesia) indicate nerve compression, a common symptom of compartment syndrome.
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