A 45-year-old male presents to the emergency department after experiencing profuse vomiting and diarrhea for 3 days. His blood pressure is 90/60 mmHg, heart rate is 110 beats per minute, and mucous membranes are dry. Which of the following interventions should the nurse prioritize?
Encourage oral intake of water
Administer potassium-sparing diuretic
Restrict fluid intake
Administer IV bolus of normal saline
The Correct Answer is D
A. Encouraging oral intake may not be effective due to the patient's likely need for more rapid rehydration given his low blood pressure and heart rate.
B. A potassium-sparing diuretic is inappropriate in this situation, as the patient is already experiencing fluid loss and requires rehydration, not diuresis.
C. Restricting fluid intake would be contraindicated as the patient is in a state of dehydration and hypotension.
D. Administering an IV bolus of normal saline is the priority intervention to quickly restore fluid volume and improve blood pressure and hydration status.
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Correct Answer is B
Explanation
A. Metabolic acidosis would be indicated by a low pH and a low HCO3, which is not present in this case since HCO3 is normal.
B. The pH of 7.32 indicates acidemia, and a PaCO2 of 50 mmHg suggests respiratory acidosis as the body is retaining carbon dioxide, contributing to the low pH. The HCO3 is normal, indicating that there is no metabolic compensation occurring.
C. Respiratory alkalosis would show a high pH and low PaCO2, which is not the case here.
D. Metabolic alkalosis would present with a high pH and elevated HCO3, which is also not present in these ABG results.
Correct Answer is A
Explanation
A. A phlebotomist collecting blood from clients who have HIV is at the greatest risk due to the potential for exposure to infected blood, especially if safety precautions are not properly followed.
B. A nurse working for an insurance company collecting urine samples is at a lower risk, as urine is not a primary mode of HIV transmission.
C. A personal trainer working with a client who has HIV may be at risk if there are open wounds, but the risk is less compared to healthcare workers directly handling blood.
D. An occupational therapist working with a client who has HIV may have some exposure risk, but it is significantly lower than that of a phlebotomist who handles blood samples.