91. A 19-year-old victim of trauma is admitted to an emergency department with a blood pressure of 80/50 mm Hg, and a heart rate of 130 bpm. Which action should a nurse take first?
91. A 19-year-old victim of trauma is admitted to an emergency department with a blood pressure of 80/50 mm Hg, and a heart rate of 130 bpm. Which action should a nurse take first?
. Give 1 liter of D5W IV as fast as possible.
. Give 1 liter NS IV as fast as possible.
. Start an additional large-bore IV as saline lock.
. Calculate the anion gap before selecting IV fluid.
Test-Taking Tip
This is a priority question. The client shows signs of shock. Without additional data, choose an isotonic solution.
Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies
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Answer 1 is incorrect because 5% dextrose in water (D5W) is not an appropriate fluid for volume resuscitation. When the sugar is metabolized, all that remains is water and almost two thirds of the infused volume will transfer into cells, which will not increase circulating volume. Answer 2 is correct because this client is in shock and requires rapid volume infusion with IV normal saline (NS). Answer 3 is incorrect because, while it may be useful to have a second large-bore IV, it does not take priority over starting IV fluids with normal saline. Answer 4 is incorrect because, regardless of the anion gap, the client will need normal saline to raise the BP.