A patient with gastroenteritis is experiencing persistent vomiting and diarrhea. Which nursing intervention should be prioritized to prevent complications associated with hypovolemia?
Encourage the patient to eat solid foods to regain energy.
Initiate intravenous fluid therapy to restore fluid balance.
Administer antiemetic medication to control vomiting.
Monitor the patient's weight daily to assess fluid status.
The Correct Answer is B
Rationale:
A. Encouraging the patient to eat solid foods may be appropriate once vomiting has subsided, but during active gastroenteritis with persistent vomiting and diarrhea, oral intake is often insufficient to prevent dehydration. Relying on food alone does not address acute fluid loss.
B. Initiating intravenous (IV) fluid therapy is the priority intervention. Persistent vomiting and diarrhea can lead to rapid fluid and electrolyte loss, resulting in hypovolemia, hypotension, tachycardia, and potential shock. IV fluids provide immediate restoration of circulating volume, correct electrolyte imbalances, and prevent life-threatening complications.
C. Administering antiemetics can help reduce nausea and vomiting, but it does not correct the underlying fluid deficit. While controlling vomiting supports oral intake, IV fluid replacement is more urgent to stabilize the patient.
D. Monitoring daily weight is useful for tracking fluid balance, but it is a secondary assessment tool. It does not intervene in acute hypovolemia and cannot replace prompt fluid resuscitation.
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Related Questions
Correct Answer is C
Explanation
Rationale:
A. Administering analgesics may help relieve pain, but it does not address the life-threatening concern of post-operative bleeding. Giving analgesics before stabilizing the patient could mask worsening symptoms and delay critical interventions.
B. Preparing the patient for an emergency endoscopic procedure may eventually be necessary, but the first priority is stabilizing hemodynamics. Endoscopy cannot safely be performed if the patient is unstable due to ongoing bleeding.
C. Initiating a large-bore IV for fluid resuscitation and notifying the surgical team is the priority intervention. Hypotension, tachycardia, and abdominal distention following surgery are classic signs of postoperative hemorrhage or internal bleeding. Rapid vascular access allows for fluid and blood product administration, which is essential to restore circulating volume and maintain perfusion. Early notification of the surgical team ensures prompt evaluation and intervention, potentially preventing shock or organ failure.
D. Encouraging ambulation is inappropriate in a patient showing signs of hemodynamic instability. Ambulation could worsen hypotension, increase bleeding, and delay urgent resuscitative measures.
Correct Answer is B
Explanation
Rationale:
A. Providing reading materials can be helpful for patient education, but in a preoperative emergency situation, the client may need immediate, clear, and understandable verbal explanation. Relying solely on materials may not alleviate anxiety or clarify the situation promptly.
B. "This means that scar tissue formed from the healing of a past abdominal surgery is now constricting the opening in your intestine." This statement is the best response because it directly explains the medical term "adhesions" in simple, clear language. It addresses the client’s immediate concern, helps reduce anxiety by providing understanding, and ensures the patient is informed about the reason for the obstruction and surgery.
C. Saying, "The most important thing is that now you are here, and it is going to get taken care of," while reassuring, does not provide any information about the condition or answer the client’s question. It may leave the client confused or anxious, as the request was for an explanation.
D. Saying, "It's okay. It happens all the time and I've seen a lot of clients with this issue," may minimize the client’s concerns. While it attempts to normalize the situation, it fails to educate or clarify, and can make the patient feel dismissed or unheard.
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