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Difficulty: MediumPhysiological Adaptation

A triage nurse evaluates a client presenting with a 4-day history of frequent, watery diarrhea and an inability to drink fluids. The client is lethargic and exhibits delayed capillary refill. Assessment reveals a heart rate of 124 beats/minute, a respiratory rate of 30 breaths/minute with deep chest excursions, and a blood pressure of 94/76 mm Hg. Arterial blood gas (ABG) testing indicates a pH of 7.25, PaCO2 of 27 mm Hg, HCO3 of 12 mEq/L, and PaO2 of 96 mm Hg on room air. Which of the following actions should the nurse perform FIRST?

  1. Start a rapid infusion of prescribed isotonic crystalloid fluids.Answer
  2. B
    Give a prescribed antidiarrheal medication and reassess the client in one hour.
  3. C
    Instruct the client to take slow, shallow breaths to correct the carbon dioxide level.
  4. D
    Elevate the head of the bed to a high-Fowler's position to ease the work of breathing.

Answer

The priority action is to start a rapid infusion of prescribed isotonic crystalloid fluids to treat hypovolemic shock and restore tissue perfusion.
The correct answer directly addresses the most life-threatening condition: hypovolemic shock. The client's history of severe fluid loss, combined with lethargy, tachycardia, and a dangerously narrowed pulse pressure, necessitates immediate intravascular volume replacement with isotonic fluids to ensure adequate tissue perfusion.

Step-by-Step Solution

1
Analyze the client's vital signs and clinical presentation.
The client has a heart rate of 124 beats/minute, a blood pressure of 94/76 mm Hg (narrowed pulse pressure of 18 mm Hg), lethargy, and delayed capillary refill.
These findings are classic early indicators of hypovolemic shock requiring immediate circulatory support.
2
Interpret the arterial blood gas (ABG) results in the context of the client's history.
The pH of 7.25 and HCO3 of 12 mEq/L indicate severe metabolic acidosis (from bicarbonate loss in diarrhea and lactic acid from poor perfusion). The PaCO2 of 27 mm Hg and deep, rapid respirations indicate respiratory compensation.
Understanding the acid-base imbalance confirms that the respiratory changes are compensatory and that the primary derangement is metabolic and circulatory.
3
Prioritize nursing interventions using the ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs.
Circulatory collapse is the most immediate life-threatening issue. Fluid resuscitation is the priority intervention.
Restoring intravascular volume will improve tissue perfusion, resolve the lactic acidosis component, and stabilize the client's hemodynamics.

Key Concept

Prioritization of care for a client experiencing hypovolemic shock and compensatory metabolic acidosis.
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Topics

Physiological Adaptation

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