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Difficulty: HardPhysiological Adaptation

A nurse is evaluating a client who was admitted with massive hematemesis from ruptured esophageal varices. The client has received 2 liters of 0.9% sodium chloride intravenously over the past hour. Current vital signs are: blood pressure 86/52 mm Hg, heart rate 122/min, respiratory rate 24/min, and oxygen saturation 95% on room air. The client's skin is cool and clammy, and urinary output was 10 mL over the last hour. Arterial blood gas (ABG) results show a pH of 7.29, PaCO2 of 34 mm Hg, and HCO3- of 15 mEq/L. Which of the following is the priority nursing intervention?

  1. Prepare to administer type-specific packed red blood cellsAnswer
  2. B
    Initiate a prescribed continuous intravenous infusion of norepinephrine
  3. C
    Administer intravenous sodium bicarbonate to correct the acidosis
  4. D
    Apply supplemental oxygen at 2 L/min via nasal cannula

Answer

The correct answer is to prepare to administer type-specific packed red blood cells.
The client is in uncompensated hypovolemic shock due to acute blood loss. Despite receiving 2 liters of crystalloid fluid, the client remains hypotensive, tachycardic, and oliguric, indicating that intravascular volume is still profoundly depleted. The ABG reveals metabolic acidosis, which is a direct result of tissue hypoperfusion leading to anaerobic metabolism and lactic acid buildup. The priority intervention is to administer packed red blood cells to restore both intravascular volume and the oxygen-carrying capacity needed to reverse tissue hypoxia and acidosis.

Step-by-Step Solution

1
Analyze the vital signs and clinical presentation.
Hypotension (86/52), tachycardia (122), oliguria (10 mL/hr), and cool/clammy skin indicate progressive hypovolemic (hemorrhagic) shock despite initial crystalloid resuscitation.
Recognizing the stage and type of shock dictates the next physiological intervention.
2
Interpret the Arterial Blood Gas (ABG) results in the context of the clinical picture.
pH 7.29 and HCO3- 15 mEq/L indicate metabolic acidosis. In the context of shock, this is lactic acidosis caused by anaerobic metabolism from poor tissue perfusion.
Understanding the source of the acidosis prevents administering inappropriate treatments like sodium bicarbonate.
3
Determine the highest priority intervention to reverse the underlying pathophysiology.
The client has lost whole blood. Crystalloids (normal saline) increase volume temporarily but do not carry oxygen. Blood products are required to restore both volume and oxygen-carrying capacity, which will stop lactic acid production.
Clinical prioritization must target the root cause of the decompensation.

Key Concept

Hemorrhagic Shock Management and Lactic Acidosis
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Topics

Physiological Adaptation

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