# A 65-year-old patient with a history of diabetes is admitted with persistent vomiting for the past 24 hours. The patient appears lethargic, has dry mucous membranes, and decreased skin turgor. Vital signs are: temperature 99.2°F (37.3°C), heart rate 110 bpm, respiratory rate 22/min, blood pressure 100/60 mmHg. What is the priority nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542038 > language: ko > subject: Child Health ## 문제 A 65-year-old patient with a history of diabetes is admitted with persistent vomiting for the past 24 hours. The patient appears lethargic, has dry mucous membranes, and decreased skin turgor. Vital signs are: temperature 99.2°F (37.3°C), heart rate 110 bpm, respiratory rate 22/min, blood pressure 100/60 mmHg. What is the priority nursing intervention? ## 보기 1. Initiate intravenous fluid therapy as ordered **✔ 정답** 2. Administer antiemetic medication orally 3. Encourage small, frequent sips of clear liquids 4. Position the child in high Fowler's position **정답: 1** ## 해설 IV fluid therapy is priority for severe dehydration with persistent vomiting to restore intravascular volume and prevent shock. Oral antiemetics or fluids are ineffective due to vomiting. ## 심화 해설 Clinical Presentation Analysis The patient presents with persistent vomiting for 24 hours, lethargy, dry mucous membranes, decreased skin turgor, tachycardia (heart rate 110 bpm), and relative hypotension (BP 100/60 mmHg). This constellation of findings indicates significant fluid volume deficit secondary to gastrointestinal losses. The history of diabetes adds risk because hyperglycemia can induce osmotic diuresis, compounding the hypovolemia. The elevated heart rate is a compensatory mechanism to maintain cardiac output in the setting of decreased intravascular volume, and the borderline low blood pressure signals that compensatory mechanisms are beginning to fail, placing the patient at risk for progression to hypovolemic shock. Pathophysiology of Hypovolemic Shock Hypovolemic shock is a life-threatening condition resulting from a significant reduction in intravascular volume, which impairs oxygen delivery to vital organs. As described in the evidence synthesis by Wang et al., common causes include fluid loss from the gastrointestinal tract, such as persistent vomiting [1]. The underlying mechanism involves decreased preload, leading to reduced stroke volume and cardiac output. The body initially compensates with sympathetic nervous system activation, producing tachycardia and vasoconstriction. However, when volume loss exceeds the body's compensatory capacity, tissue hypoperfusion, cellular hypoxia, and eventual organ failure occur. The nurse's role in early recognition of these compensatory signs—tachycardia, decreased skin turgor, dry mucous membranes—is critical to prevent decompensation [1]. Priority Intervention: Fluid Resuscitation The priority nursing intervention is to initiate intravenous fluid therapy as ordered. The evidence-based review by Wang et al. emphasizes that prompt fluid resuscitation is critical in managing hypovolemic shock, with nurses playing a central role in timely intervention [1]. Intravenous access and isotonic crystalloid administration directly address the core problem of intravascular volume depletion by restoring circulating volume, improving preload, and enhancing tissue perfusion. In this scenario, the patient's oral route is compromised due to persistent vomiting, making oral rehydration attempts ineffective and potentially dangerous due to aspiration risk. Administering an oral antiemetic is contraindicated when the patient is actively vomiting and has an unsecured airway. Positioning in high Fowler's position could worsen hypotension by reducing venous return. Therefore, establishing IV access and beginning fluid resuscitation is the immediate, evidence-based nursing action that aligns with the best practices for managing evolving hypovolemic shock [1].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 ## 임상 시나리오 Clinical Management of Hypovolemia Assessment Priorities - **Hemodynamic Monitoring:** Track orthostatic vital signs, continuous heart rate, and blood pressure trends to detect early decompensation. - **Volume Status Indicators:** Monitor mucous membranes, skin turgor, urine output (goal >0.5 mL/kg/hr), and daily weights as the most reliable measure of fluid balance. - **Laboratory Surveillance:** Monitor BUN, creatinine, hematocrit, and electrolytes, with particular attention to potassium and sodium shifts during rehydration. Intervention Pathway - **Vascular Access:** Establish two large-bore IV lines (18-gauge or larger) for rapid volume resuscitation. - **Fluid Resuscitation:** Administer isotonic crystalloids (0.9% NaCl or Lactated Ringer's) per order, typically starting with a 500-1000 mL bolus in adults. - **Reassessment:** Evaluate lung sounds, respiratory status, and blood pressure every 15 minutes during active resuscitation to prevent fluid overload. - **Antiemetic Administration:** Once IV access is secured, administer IV antiemetics to control vomiting and facilitate further oral intake when appropriate. Diabetes-Specific Considerations - **Glucose Monitoring:** Check blood glucose every 1-2 hours; hyperglycemia can worsen osmotic diuresis and exacerbate fluid loss. - **Ketone Assessment:** Evaluate for ketonuria or elevated serum ketones to rule out diabetic ketoacidosis, which requires insulin therapy alongside fluid replacement. - **Medication Adjustment:** Hold oral hypoglycemic agents during acute illness; coordinate with provider for insulin coverage during NPO status. **Safety Alert:** Never administer oral medications or fluids to a patient with persistent vomiting due to high aspiration risk and ineffective absorption. The priority is always IV access and volume restoration to prevent progression to hypovolemic shock. ## 핵심 개념 - **Hypovolemic Shock** — A life-threatening condition caused by a significant loss of intravascular volume, leading to inadequate oxygen delivery to tissues and organ failure. - **Fluid Volume Deficit** — A state of decreased intravascular, interstitial, and/or intracellular fluid, often manifested by tachycardia, hypotension, dry mucous membranes, and decreased skin turgor. - **Compensatory Tachycardia** — An increase in heart rate as the body's initial response to maintain cardiac output when stroke volume decreases due to hypovolemia. ## 같은 주제 문제 - [A 6-month-old infant is brought to the emergency department by parents who report that the…](https://mymerci.kr/pages/nclex_q.php?qn_id=542035) - [A 4-month-old infant is brought to the emergency department by parents who report that the…](https://mymerci.kr/pages/nclex_q.php?qn_id=542036) - [A 6-month-old infant is brought to the emergency department by parents who report that the…](https://mymerci.kr/pages/nclex_q.php?qn_id=542037) - [A 4-year-old child is admitted to the pediatric unit with persistent vomiting for the past…](https://mymerci.kr/pages/nclex_q.php?qn_id=542039) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._