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. Flushing of the skin is not typical in hypovolemic shock; rather, the skin is usually cool and clammy due to vasoconstriction.
B. Oliguria, or decreased urine output, is expected in hypovolemic shock as the kidneys receive less blood flow, leading to reduced urine production.
C. Bradypnea is not a common finding in hypovolemic shock; instead, tachypnea (increased respiratory rate) is typically observed due to compensatory mechanisms for hypoxia and acidosis.
D. Hypertension is not expected in hypovolemic shock; instead, the client typically presents with hypotension due to decreased blood volume and pressure.
Correct Answer is D
Explanation
A. The conversion of RNA into DNA is a critical step in the HIV lifecycle, but it does not directly lead to opportunistic infections; instead, it allows the virus to integrate into the host’s genome.
B. Having reverse transcriptase enzyme is a characteristic of retroviruses like HIV that facilitates replication, but it does not cause opportunistic infections directly.
C. HIV containing a single strand of genetic material is a feature of its classification as a retrovirus but is not related to the risk of opportunistic infections.
D. The ability of HIV to target and destroy CD4 lymphocytes is the key reason for opportunistic infections. CD4 cells are crucial for the immune response, and their depletion leads to immunosuppression, making the client susceptible to infections that would not typically affect an individual with a healthy immune system.