Practice Question
A nurse is caring for a client in the emergency department (ED).
Answer Choices:
Rationale:
Initiate oxygen:
🟣The priority intervention is to administer supplemental oxygen due to the client’s hypovolemic state and signs of impaired perfusion.
🟣The blood pressure (88/50 mm Hg) and elevated heart rate (112/min) indicate the body is compensating for volume loss.
🟣Additionally, the oxygen saturation has dropped to 94%, below the prescribed threshold of 95%, indicating reduced oxygen delivery to tissues.
🟣Starting oxygen improves tissue oxygenation while other interventions are prepared.
Administer a fluid bolus:
🟣After addressing oxygenation, the next most critical intervention is to administer a 500 mL 0.9% sodium chloride IV bolus.
🟣The client shows clinical signs of moderate dehydration and possible early hypovolemic shock from prolonged vomiting and diarrhea.
🟣The fluid bolus helps restore intravascular volume, improve perfusion, stabilize vital signs, and support organ function.
🟣Timely fluid replacement is key to preventing further hemodynamic compromise.
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This question is from Custom: NUR105_Midpoint assessment_SU2 which contains 28 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Custom Exam(s)
- Answer Choices: 0