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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View Related questions
Correct Answer is C
Explanation
A. Anuria, or the absence of urine output, indicates significant renal impairment and is a later sign of shock.
B. Hypotension is a classic sign of shock but occurs after compensatory mechanisms have failed.
C. An increased respiratory rate is often one of the earliest indicators of shock, as the body attempts to compensate for reduced oxygenation and tissue perfusion by increasing respiratory effort.
D. A decreased level of consciousness can occur with prolonged shock but typically presents after other compensatory mechanisms have been overwhelmed.
Correct Answer is ["A","C"]
Explanation
A. Orthostatic hypotension is a common sign of hypovolemia, as the lack of fluid volume can lead to a drop in blood pressure when changing positions.
B. Bradycardia is not typically associated with fluid volume deficit; tachycardia is more common as the body tries to compensate for low blood volume.
C. Decreased skin turgor is a classic sign of dehydration and fluid volume deficit, indicating reduced skin elasticity.
D. Weight gain is associated with fluid volume overload, not deficit.
E. Pulmonary edema is related to fluid volume overload or congestive heart failure, not hypovolemia.