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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?

A.

Encourage oral intake of water

B.

Administer potassium-sparing diuretic

C.

Restrict fluid intake

D.

Administer IV bolus of normal saline

Answer and Explanation

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. Pneumocystis lung infection is an opportunistic infection that typically occurs in later stages of HIV/AIDS when the immune system is significantly weakened, not during the initial phase of infection.

B. Fungal and bacterial infections are also associated with advanced HIV/AIDS due to immunosuppression and not seen in the initial phase of infection.

C. Flu-like symptoms and night sweats are common initial symptoms of HIV infection, often occurring 2-4 weeks after exposure during the acute retroviral syndrome phase.

D. Kaposi's sarcoma is a cancer associated with advanced HIV/AIDS and does not manifest during the initial symptoms of infection.

Correct Answer is B

Explanation

A. Respiratory alkalosis is characterized by a high pH and low PaCO2, which is not evident in this scenario where the pH is low and PaCO2 is elevated.

B. The low pH of 7.3 indicates acidemia, and the elevated PaCO2 of 50 mm Hg suggests respiratory acidosis, where the body is retaining carbon dioxide, leading to an increase in acidity.

C. Metabolic acidosis would present with a low pH and a normal or decreased PaCO2, which is not the case here since the PaCO2 is elevated.

D. Metabolic alkalosis would show a high pH and elevated HCO3 levels, which is not consistent with the given ABG results.

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