# A 72-year-old woman is brought to the emergency department with vomiting and diarrhea. She is lethargic and confused, skin turgor is decreased, and her findings are shown below. Which nursing intervention is the PRIORITY?

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## 문제

A 72-year-old woman is brought to the emergency department with vomiting and diarrhea. She is lethargic and confused, skin turgor is decreased, and her findings are shown below. Which nursing intervention is the PRIORITY?

•Vital signs: BP 82/50 mmHg, pulse 118 beats/min, respirations 24 breaths/min, temperature 97.2°F (36.2°C), SpO₂ 94%

•Laboratory: sodium (Na) 148 mEq/L, potassium (K) 3.1 mEq/L, chloride (Cl) 118 mEq/L, blood urea nitrogen (BUN) 42 mg/dL, creatinine (Cr) 1.6 mg/dL

•Urinalysis: specific gravity 1.032, ketones negative

## 보기

1. Monitor vital signs every 15 minutes and observe the trend.
2. Encourage oral intake and provide fluids by mouth.
3. Report the hypertonic dehydration to the provider.
4. Administer diluted potassium by intravenous infusion.
5. Administer 0.9% normal saline by intravenous infusion. **✔ 정답**

**정답: 5**

## 해설

This client shows signs of hypovolemic shock—hypotension, tachycardia, and decreased skin turgor—along with severe dehydration accompanied by hypernatremia (Na 148 mEq/L). The priority intervention is intravenous infusion of an isotonic solution, 0.9% normal saline, to restore intravascular volume. Correction of hypokalemia should be initiated only after circulating volume is restored and adequate urine output is confirmed.

## 심화 해설

Identifying the Core Problem

First, consider the client's overall picture: vomiting and diarrhea have produced severe fluid loss. The blood pressure of 82/50 mmHg indicates hypotension, and the pulse of 118 beats/min reflects tachycardia. This is the classic sympathetic nervous system response compensating for reduced cardiac output, and it signals that the compensatory mechanisms of hypovolemic shock have already reached their limit. The altered level of consciousness and decreased skin turgor are strong clinical clues that organ perfusion is seriously compromised.

On laboratory review, sodium is elevated at 148 mEq/L, indicating hypernatremia. This occurs because water was lost in greater proportion than sodium through vomiting and diarrhea, or because insensible losses such as perspiration increased. The elevated BUN of 42 mg/dL together with a creatinine of 1.6 mg/dL reflects prerenal acute kidney injury (AKI) resulting from inadequate renal blood flow. The markedly elevated urine specific gravity of 1.032 likewise represents the kidneys' attempt to conserve water maximally. Together, these findings clearly establish that the client is in a state of hypertonic dehydration (hypovolemic hypernatremia).

Setting Nursing Priorities

For a client in hypovolemic shock, the most urgent goal is restoring circulating blood volume to maintain organ perfusion. The evidence[1] emphasizes that prompt fluid resuscitation is critical in hypovolemic shock and that nurses play a central role in early recognition and intervention. The evidence[2] similarly describes the need for immediate, effective fluid resuscitation to stabilize hemodynamics in clients with acute gastrointestinal hemorrhage.

When selecting a fluid for this client, the elevated plasma sodium of 148 mEq/L is an important consideration. The evidence[4] warns that mortality can exceed 40% when hypernatremia is severe. A hypotonic solution would gradually correct the plasma sodium concentration. In shock, however, rapidly restoring intravascular volume takes precedence over the rate of sodium correction. 0.9% normal saline has a sodium concentration of 154 mEq/L, making it an isotonic solution only slightly higher than this client's plasma. Because most of an isotonic solution remains within the vascular space, it is the most effective choice for rapidly expanding circulating blood volume. The evidence[3] evaluated the optimal fluid for volume expansion during resuscitation of hemorrhagic shock, and for a client in profound hypovolemia such as this one, rapid intravascular volume replacement with an isotonic crystalloid is consistent with evidence-based practice.

Reviewing each option: measuring vital signs (option 1) is important for ongoing monitoring but does not directly treat the shock state. Encouraging oral intake (option 2) poses an aspiration risk in a client with altered consciousness and depends on gastrointestinal absorption, making rapid volume replacement impossible. Notifying the provider (option 3) is certainly necessary, but the nurse can implement interventions immediately while awaiting orders. Potassium replacement for hypokalemia (3.1 mEq/L, option 4) is important, but giving potassium before urine output is confirmed can cause dangerous hyperkalemia, and electrolyte correction is secondary until circulating volume is restored. Therefore, intravenous infusion of normal saline (option 5) is the priority nursing intervention for resolving this client's life-threatening hypovolemic shock.References (research sources)

- [1]Best evidence for fluid resuscitation nursing in hypovolemic shock patients in emergency care based on GRADE system.Research articleWang Y, Lin J, Lin Y. (2026) · DOI: 10.2478/abm-2026-0009

- [2]Evidence-Based Fluid Resuscitation Protocol for Patients With Acute Gastrointestinal Hemorrhage: An Evidence Summary.Research articleChen Y, Dai L, Guo Q, Yang S. (2026) · DOI: 10.1177/00469580261435485

- [3]Volume replacement in the resuscitation of trauma patients with acute hemorrhage: an umbrella review.Research articleGianola S, Castellini G, Biffi A, Porcu G, Napoletano A, Coclite D, D'Angelo D, Di Nitto M, Fauci AJ, Punzo O, Iannone P, Chiara O, Italian National Institute of Health guideline working group. (2023) · DOI: 10.1186/s12245-023-00563-4

- [4]Successful Management of Life-Threatening Hypernatremia (Na⁺ 186 mmol/L): A Case Report.Case reportBalkan B, Kaya E, Özcanoğlu HD, Balkan AO, Yılmaz G. (2025) · DOI: 10.7759/cureus.93176

## 임상 시나리오

Fluid Resuscitation Guide for the Client in Hypovolemic ShockPrioritizing nursing interventions in dehydration with hypernatremia
Hypotension (82/50 mmHg) and tachycardia accompanied by decreased level of consciousness and poor skin turgor point to hypovolemic shock, so restoring circulating blood volume is the top priority.

Even when plasma sodium is 148 mEq/L, indicating hypernatremia, a client in shock requires rapid intravascular volume replacement with an isotonic crystalloid (0.9% normal saline).

Elevated BUN (42 mg/dL) and creatinine (1.6 mg/dL) with a high urine specific gravity (1.032) indicate prerenal acute kidney injury from reduced renal perfusion; response to fluid replacement determines the potential for recovery.

CautionOral rehydration is contraindicated in a client with altered consciousness because of the high aspiration risk and slow effect. Correction of hypokalemia should wait until adequate urine output is confirmed in order to prevent hyperkalemia.

## 핵심 개념

- **Hypovolemic shock** — A state in which rapid loss of body fluid or blood reduces circulating blood volume and impairs tissue perfusion. Findings include tachycardia, hypotension, and decreased level of consciousness.
- **Hypernatremia** — A plasma sodium concentration greater than 145 mEq/L. It occurs when water loss exceeds sodium loss and causes cellular dehydration.
- **Prerenal acute kidney injury** — Functional renal failure caused by inadequate blood flow to the kidneys. BUN and creatinine rise, and function may recover with fluid replacement.
- **Isotonic crystalloid solution** — A fluid with an osmolality similar to plasma (e.g., 0.9% normal saline). It rapidly expands intravascular volume and is effective for correcting hypovolemia.

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