QLexNursing

1. Initiate continuous cardiac monitoring

🟦 The client has hypokalemia (K⁺ 3.0 mEq/L), which places her at high risk for life-threatening cardiac dysrhythmias, making continuous cardiac monitoring a top priority.

🟦 In the presence of dehydration, electrolyte loss, and hypotension, the myocardium becomes extremely irritable and susceptible to conduction abnormalities.

🟦 Because potassium imbalances alter the resting membrane potential of cardiac cells, early ECG monitoring helps detect changes such as PVCs, ventricular tachycardia, or ST abnormalities.

🟦 Cardiac monitoring also allows the healthcare team to safely administer IV fluids that may further shift electrolytes during resuscitation.

🟦 Given the patient’s tachycardia (HR 106) and low blood pressure (85/54), continuous monitoring provides essential information about cardiac response to therapy.

🟦 This intervention directly supports ABC priorities (circulation), making it an essential action at this time.

🟦 Early monitoring prevents deterioration and provides immediate data if electrolyte replacement becomes necessary.

2. 0.9% Sodium chloride bolus infusion at 500 mL/hr

🟦 This client shows clear signs of hypovolemic shock: low blood pressure, tachycardia, dry mucous membranes, skin tenting, and elevated sodium/osmolality.

🟦 Rapid isotonic fluid replacement with normal saline is critical to restore intravascular volume, improve tissue perfusion, and correct the severe dehydration caused by profuse watery diarrhea.

🟦 Immediate fluid administration helps raise blood pressure, increase cardiac output, and prevent organ dysfunction such as acute kidney injury.

🟦 Without prompt isotonic fluid resuscitation, the patient’s perfusion would continue to decline, worsening lactic acidosis and risking shock progression.

🟦 0.9% NS is the safest and most appropriate fluid because it expands vascular volume without altering serum osmolality further.

🟦 Improving volume status will help stabilize vital signs, reduce compensatory tachycardia, and enhance overall hemodynamic stability.

🟦 This is an urgent life-saving intervention, making it a top priority.

3. Titrate oxygen to SpO₂ greater than 95%

🟦 The client’s oxygen saturation is 89% on room air, indicating significant hypoxemia, which must be corrected immediately to maintain adequate cellular oxygenation.

🟦 Hypoxia worsens neurological status, contributing to lethargy and confusion, both of which are already present in this client’s altered mental state.

🟦 Supplemental oxygen increases arterial oxygen delivery and helps counteract the impaired perfusion caused by severe dehydration.

🟦 Improving oxygenation ensures vital organs—including the brain and kidneys—receive adequate oxygen, reducing the risk of tissue injury.

🟦 Titrating oxygen to >95% follows ABCs—Airway and Breathing, which always take precedence when abnormalities are detected.

🟦 Oxygen delivery is also important during fluid resuscitation, as restoring volume increases metabolic demand and oxygen consumption.

🟦 Ensuring adequate oxygen saturation prevents further decline and supports stabilization during the acute phase of treatment.

❌ Incorrect Options

Weigh the client daily on the same scale

❌ Daily weights are important for monitoring hydration trends but are not an immediate priority in a hemodynamically unstable patient.

❌ Life-saving interventions such as oxygenation, perfusion restoration, and cardiac monitoring come first.

Draw blood for a complete blood count

❌ The patient already had blood drawn at 0800, and a CBC is not an immediate life-saving priority in comparison to stabilizing ABCs and perfusion.

❌ Additional labs can be collected later, once the patient is hemodynamically supported.

Document the client’s intake and output

❌ Although important for fluid management, I&O documentation is a secondary task, not a priority during acute hypotension and hypoxia.

❌ Stabilization of airway, breathing, circulation, and electrolytes must occur before documentation tasks.