An emergency department nurse evaluates a client presenting with a three-day history of pr… — NCLEX-RN

An emergency department nurse evaluates a client presenting with a three-day history of profound watery diarrhea and poor oral fluid intake. The client exhibits marked lethargy and dry mucous membranes. Initial assessment reveals a heart rate of $116\text{ beats/min}$ , a respiratory rate of $28\text{ breaths/min}$ , and a blood pressure of $94/60\text{ mm Hg}$ . Arterial blood gas analysis demonstrates a pH of $7.29$ , a $PaCO_2$ of $32\text{ mm Hg}$ , and an $HCO_3^-$ of $15\text{ mEq/L}$ . Which action represents the highest priority for this client?

Establish intravenous access and commence a prescribed crystalloid fluid challengeCevap
B
Prepare to administer prescribed intravenous sodium bicarbonate to correct the acidosis
C
Collect a stool specimen to determine the underlying infectious etiology
D
Administer a prescribed oral anti-motility medication to halt further fluid losses

Cevap

Establish intravenous access and commence a prescribed crystalloid fluid challenge

The correct action directly addresses the most immediate threat to the client's life: hypovolemic shock. The clinical presentation of lethargy, tachycardia, tachypnea, and hypotension indicates poor tissue perfusion. Administering an intravenous crystalloid fluid challenge will rapidly expand the intravascular volume, improve cardiac output, and reverse the tissue hypoxia that is exacerbating the metabolic acidosis.

Adım Adım Çözüm

Analyze the vital signs and clinical presentation.

The client has tachycardia (

116\text{ beats/min}

), tachypnea (

28\text{ breaths/min}

), borderline low blood pressure (

94/60\text{ mm Hg}

), and lethargy.

Identifying abnormal parameters establishes that the client is experiencing severe volume depletion and early hypovolemic shock.

Interpret the arterial blood gas (ABG) values.

pH is

7.29

(acidosis),

PaCO_2

32\text{ mm Hg}

(partial respiratory compensation), and

HCO_3^-

15\text{ mEq/L}

(primary metabolic acidosis).

Severe diarrhea causes a direct loss of bicarbonate, and subsequent poor tissue perfusion adds lactic acid, resulting in significant metabolic acidosis.

Prioritize nursing interventions based on ABCs (Airway, Breathing, Circulation).

Circulatory collapse is the most immediate life-threatening issue. Intravenous fluid replacement takes precedence.

Restoring intravascular volume treats the root cause of the shock state and helps correct the metabolic acidosis by improving tissue perfusion.

Anahtar Kavram

Hypovolemic Shock and Metabolic Acidosis Management

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Cevap

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