Examkin

Soru

Zorluk: OrtaReduction of Risk Potential

An older adult client is being monitored in the surgical intensive care unit following an open abdominal aortic aneurysm repair. Over the past hour, the client's urine output has dropped to 15 mL15\text{ mL}. Current vital signs reveal a blood pressure of 86/52 mm Hg86/52\text{ mm Hg}, a heart rate of 122 beats/minute122\text{ beats/minute}, and a respiratory rate of 26 breaths/minute26\text{ breaths/minute}. Recent arterial blood gas results show a pH of 7.317.31, a PaCO2 of 34 mm Hg34\text{ mm Hg}, and an HCO3 of 15 mEq/L15\text{ mEq/L}. Which intervention should the nurse implement first?

  1. Administer a prescribed rapid isotonic intravenous fluid bolus.Cevap
  2. B
    Elevate the head of the bed to a high Fowler's position.
  3. C
    Coach the client to take slow, deep breaths to manage the respiratory rate.
  4. D
    Perform a comprehensive auscultation of the client's bowel sounds.

Cevap

Administer a prescribed rapid isotonic intravenous fluid bolus.
The client is exhibiting clear signs of hypovolemic shock (hypotension, tachycardia, oliguria) and uncompensated metabolic acidosis (low pH, normal-to-low PaCO2, low HCO3), which likely result from tissue hypoperfusion and subsequent lactic acid buildup following major vascular surgery. Administering an isotonic fluid bolus is the priority intervention because it directly replenishes intravascular volume, improves cardiac output, restores tissue perfusion, and resolves the root cause of the acidosis.

Adım Adım Çözüm

1
Analyze the vital signs and urine output.
The client has hypotension, tachycardia, and oliguria.
These findings are classic indicators of decreased cardiac output and hypoperfusion (shock).
2
Interpret the arterial blood gas (ABG) results.
The ABG indicates uncompensated metabolic acidosis.
A pH below 7.357.35 and an HCO3 below 22 mEq/L22\text{ mEq/L} confirm metabolic acidosis, which is caused by lactic acid accumulation during tissue hypoperfusion.
3
Prioritize nursing interventions based on the ABCs (Airway, Breathing, Circulation).
Circulatory support is the immediate priority.
Restoring intravascular volume is critical to reversing hypovolemic shock, restoring tissue perfusion, and correcting the metabolic acidosis.

Anahtar Kavram

Early recognition and acute management of hypovolemic shock and metabolic acidosis
Bu soruyu puanla

Konular

Reduction of Risk Potential

Bu konudan daha fazla soru