The nurse is caring for a newly admitted client suspected of having bacterial gastroenteritis with frequent watery diarrhea for several days and has been unable to hold down fluids. All of the following are ordered for the client. What is the priority intervention?
Apply zinc ointment to perianal area for excoriation
Administer probiotics one capsule by mouth three times a day
Obtain a stool specimen for culture
Administer intravenous fluids at 125 mL per hour
The Correct Answer is D
A. Zinc ointment is appropriate to protect skin from breakdown due to diarrhea, but it does not address the client’s most urgent physiologic need.
B. Probiotics may support gut health, but oral administration is not appropriate when the client cannot hold down fluids and is at risk for dehydration.
C. Obtaining a stool specimen is important for identifying the infectious cause, but it is not the immediate priority.
D. The client has had several days of diarrhea and is unable to tolerate oral fluids, placing them at high risk for severe dehydration and electrolyte imbalance. Administering IV fluids at 125 mL/hr is the priority intervention to restore fluid balance and prevent hypovolemic shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Zinc ointment is appropriate to protect skin from breakdown due to diarrhea, but it does not address the client’s most urgent physiologic need.
B. Probiotics may support gut health, but oral administration is not appropriate when the client cannot hold down fluids and is at risk for dehydration.
C. Obtaining a stool specimen is important for identifying the infectious cause, but it is not the immediate priority.
D. The client has had several days of diarrhea and is unable to tolerate oral fluids, placing them at high risk for severe dehydration and electrolyte imbalance. Administering IV fluids at 125 mL/hr is the priority intervention to restore fluid balance and prevent hypovolemic shock.
Correct Answer is B
Explanation
A. Documentation and monitoring are important but not the immediate priority in an unstable, potentially life-threatening situation.
B. The nurse’s first priority is to assess for signs of hypovolemic shock (tachycardia, hypotension, tachypnea) due to bleeding and perforation. This guides urgent interventions to stabilize the client.
C. Drawing labs is appropriate but not the priority before assessing airway, breathing, and circulation (ABCs).
D. The client should not be placed prone; maintaining supine or semi-Fowler’s positioning is safer while preparing for possible surgery.
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