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Difficulty: MediumPhysiological Adaptation

A client with severe gastroenteritis and dehydration is being monitored in the emergency department. Assessment reveals a heart rate of 122 beats per minute, a blood pressure of 96/78 mm Hg, and a respiratory rate of 28 breaths per minute. An arterial blood gas (ABG) sample shows a pH of 7.31, PaCO2 of 30 mm Hg, and HCO3 of 16 mEq/L. Which of the following nursing actions is the priority?

  1. A
    Administer a prescribed intravenous dose of sodium bicarbonate.
  2. B
    Place the client in a high-Fowler's position to ease the work of breathing.
  3. C
    Prepare the client for endotracheal intubation and mechanical ventilation.
  4. Increase the rate of the prescribed intravenous isotonic fluid infusion.Answer

Answer

The priority action is to increase the rate of the prescribed intravenous isotonic fluid infusion to restore intravascular volume.
The client is exhibiting clear signs of hypovolemic shock, including tachycardia, a significantly narrowed pulse pressure, and hypotension. The arterial blood gas indicates a metabolic acidosis, likely due to lactic acid accumulation from inadequate tissue perfusion. The respiratory rate of 28 is a necessary compensatory mechanism (respiratory alkalosis) to balance the acidic pH. The priority intervention is to restore intravascular volume and tissue perfusion by administering isotonic intravenous fluids.

Step-by-Step Solution

1
Analyze the client's vital signs and hemodynamic status.
The heart rate of 122 bpm and a narrow pulse pressure (96/78 mm Hg = 18 mm Hg difference) strongly indicate early hypovolemic shock and compensatory vasoconstriction.
Identifying the primary physiological instability is the first step in clinical prioritization.
2
Interpret the arterial blood gas (ABG) results in the context of the clinical presentation.
The ABG reveals partially compensated metabolic acidosis (low pH, low HCO3, and compensatory low PaCO2). The increased respiratory rate (28 breaths/min) is the body's attempt to compensate by blowing off acid (CO2).
Understanding the acid-base balance helps determine if the respiratory symptoms are primary or secondary to a metabolic issue.
3
Determine the priority nursing intervention based on the root cause.
The metabolic acidosis is a result of lactic acid accumulation from poor tissue perfusion (hypovolemic shock). The priority is to restore circulating volume with intravenous fluids.
Treating the underlying cause of shock takes precedence over treating secondary symptoms or compensatory mechanisms.

Key Concept

Hypovolemic Shock and Compensatory Mechanisms
Estimated Time:1m 15s
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Topics

Physiological Adaptation

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