An older client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea.
Vital Signs
Heart Rate-beats/minute- 110 Respirations - breathes/minute- 28 Blood Pressure – mmHG- 80/60
Arterial blood gases (ABGs)
Ph- 7.34
PaCO2- 34 mmHg
HCO3- 20 mmol/L
pO2- 90 mmHg
Electrolytes Results
Sodium
130 mEq/L(mmol/L) Potassium
2.5 mEq/L (mmol/L) Chloride
95 mEq/L (mmol/L)
Reference Range:
Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]
Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]
Chloride [98 to 106 mEq/L (98 to 106 mmol/L)]
PaCO2 [35 to 45 mm Hg]
HCO, [21 to 28 mEq/L (21 to 28 mmol/L)] PaO2 [80 to 100 mm Hg)
The nurse inserts a urinary catheter and obtains a scant amount of dark amber output. Which intervention should the nurse implement first? (Please scroll and view each tab's information in the client's medical record before selecting the answer.)
Initiate continuous dopamine infusion at 2 mcg/kg/minute.
Administer promethazine 25 mg slow intravenous (IV) push every 4 hours.
Begin potassium chloride 10 mEq over 1 hour per secondary infusion.
Give a bolus of 0.9% sodium chloride 1,000 ml over 30 minutes.
The Correct Answer is D
A) Incorrect - Initiating continuous dopamine infusion is not a priority in this situation. The client's low blood pressure and electrolyte imbalances require more immediate attention.
B) Incorrect - Administering promethazine addresses symptoms like nausea and vomiting, but it doesn't address the primary issue of hypovolemia and low blood pressure.
C) Incorrect - Administering potassium chloride without addressing the fluid deficit can be dangerous and may lead to further electrolyte imbalances.
D) Correct- The client's vital signs and laboratory results indicate hypovolemia (low blood pressure, low sodium, and low potassium). The immediate priority is to address the fluid deficit and correct the electrolyte imbalances. Administering a bolus of 0.9% sodium chloride (normal saline) will help increase intravascular volume and improve blood pressure, as well as correct the electrolyte imbalances to some extent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
NPO status is crucial before a surgical procedure, especially when anesthesia will be administered. It helps prevent complications related to aspiration of gastric contents during the procedure. Failure to adhere to the NPO status can lead to serious respiratory problems, such as aspiration pneumonia.
It is important for the nurse to confirm the NPO status with the client to ensure that they have followed the appropriate fasting guidelines. This should be done to ensure the client's safety during the surgery.
While determining when the client last had pain medication, offering assistance to the restroom, and reviewing postoperative instructions are important aspects of preoperative care, confirming NPO status is the most critical nursing action in this particular scenario.
Correct Answer is A
Explanation
An S3 heart sound can be a normal finding during pregnancy due to increased blood volume and changes in cardiac output. It is known as a physiological S3 and is considered a benign finding in the absence of other concerning symptoms or signs.
In this case, there is no immediate need for intervention or concern regarding the S3 heart sound. It is not necessary to prepare the client for an echocardiogram or limit the client's fluids based solely on the presence of an S3 heart sound in the absence of other significant symptoms or complications.
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