Question

An older client arrives to the emergency department (ED) with reports of sever nausea and vomiting large amounts of liquid brown emesis at home. The client's vital signs are temperature 95.4 (35.2), heart rate 112 beats/min, respirations 14 breaths/minute, and blood pressure 74/37 mmHg. Which intervention is most important for the nurse to implement?

a. Maintain Strict intake and output
b. monitor blood glucose level
c. keep head of bed raised 45 degrees
d. assess warmth of extremities

Answer 1

The most important intervention for the nurse to implement is to maintain strict intake and output.

Step-by-step explanation:

The most important intervention for the nurse to implement in this case is to maintain strict intake and output. The patient is experiencing severe nausea and vomiting, which can lead to dehydration. Monitoring the intake and output of fluids is crucial to determine the level of hydration and to ensure that the patient receives appropriate fluid replacement.