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Difficulty: HardReduction of Risk Potential

A client, aged 62, presents to the acute care unit following three days of severe, intractable vomiting. Upon initial assessment, the client is lethargic with pale, cool skin. Hemodynamic monitoring reveals a heart rate of 118 beats per minute, a blood pressure of 86/52 mm Hg, and a shallow respiratory rate of 10 breaths per minute. The laboratory reports the following arterial blood gas (ABG) values: pH 7.54, PaCO2PaCO_2 50 mm Hg, HCO3−HCO_3^- 36 mEq/L, and PaO2PaO_2 88 mm Hg. Which action should the nurse take first to reduce the risk of further physiological deterioration?

  1. Administer a prescribed intravenous fluid bolus of 0.9% sodium chloride.Answer
  2. B
    Coach the client to take deep, rapid breaths to eliminate excess carbon dioxide.
  3. C
    Elevate the head of the bed to a high-Fowler's position to maximize lung expansion.
  4. D
    Assess the peripheral extremities for bounding pulses and a widened pulse pressure.

Answer

The nurse should prioritize administering a prescribed intravenous fluid bolus of 0.9% sodium chloride.
The client is experiencing hypovolemic shock and metabolic alkalosis secondary to severe vomiting. Vomiting causes a significant loss of fluid and gastric acid (hydrochloric acid). The tachycardia, hypotension, and pale skin are classic signs of decreased intravascular volume. The elevated pH and bicarbonate levels confirm metabolic alkalosis, while the shallow respiratory rate and elevated carbon dioxide level represent the body's compensatory hypoventilation to retain acid. Administering an isotonic crystalloid like 0.9% sodium chloride is the priority because it rapidly restores intravascular volume to treat the shock, and the chloride content helps the kidneys excrete excess bicarbonate, resolving the alkalosis.

Step-by-Step Solution

1
Analyze the client's vital signs and clinical presentation.
Tachycardia (118 bpm), hypotension (86/52 mm Hg), and pale, cool skin indicate hypovolemic shock due to severe fluid loss from vomiting.
Identifying the primary physiological threat is required to determine the priority intervention.
2
Interpret the arterial blood gas (ABG) results.
Elevated pH (7.54) and elevated HCO3- (36 mEq/L) indicate metabolic alkalosis resulting from the loss of gastric acid. The elevated PaCO2 (50 mm Hg) and low respiratory rate (10 breaths/min) represent a compensatory hypoventilation mechanism.
Accurate ABG interpretation ensures the nurse does not inappropriately intervene against a helpful compensatory response.
3
Select the intervention that addresses both the fluid deficit and the acid-base imbalance.
Isotonic fluid replacement with 0.9% sodium chloride is the priority action.
The fluid restores intravascular volume to treat the life-threatening shock, and the chloride content helps the kidneys excrete excess bicarbonate to correct the alkalosis.

Key Concept

Management of Hypovolemic Shock and Metabolic Alkalosis
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Topics

Reduction of Risk Potential

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