If the client is entering hypovolemic shock, the nurse anticipates which item to be a priority?
1. Maintenance of the client's airway
2. Administration of norepinephrine (Levophed)
3. Administration of sodium bicarbonate
4. Maintenance of volume
Correct Answer: 4
Rationale 1: Maintenance of the client's airway is incorrect because the airway would have been established as an initial action.
Rationale 2: Administration of norepinephrine (Levophed) is incorrect because it would be administered in cardiogenic shock.
Rationale 3: Administration of sodium bicarbonate is incorrect because sodium bicarbonate may be administered to counteract the acidosis that can occur during shock.
Rationale 4: If the client has lost a significant amount of blood or other body fluids, immediate maintenance of blood volume through the administration of fluid and electrolytes or blood products is essential. Sodium bicarbonate may be administered to counteract the acidosis that can occur during shock. Norepinephrine would be administered in cardiogenic shock. The client's airway would be established as an initial action, and treatment of the underlying cause would follow next.
Global Rationale: If the client has lost a significant amount of blood or other body fluids, immediate maintenance of blood volume through the administration of fluid and electrolytes or blood products is essential. Sodium bicarbonate may be administered to counteract the acidosis that can occur during shock. Norepinephrine would be administered in cardiogenic shock. The client's airway would be established as an initial action, and treatment of the underlying cause would follow next. Maintenance of the client's airway is incorrect because the airway would have been established as an initial action. Administration of norepinephrine (Levophed) is incorrect because it would be administered in cardiogenic shock. Administration of sodium bicarbonate is incorrect because sodium bicarbonate may be administered to counteract the acidosis that can occur during shock.
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