A patient complains of nausea, vomiting, and diarrhea for 5 days. The nurse assesses the mucousmembranes as pale and dry. The client has sunken eyes with the following vital signs: pulse 122and thready, respirations 23, blood pressure 78/55, temperature 101.8°F oral. Which is thepriority nursing intervention?
O Assess vital signs every 15 minutes.
O Initiate oral rehydration therapy at 100 mL/kg of oral rehydration solution over 4 hours.
O Request an order from the physician for IV rehydration therapy.
O Obtain stool specimen for analysis.

Prolonged nausea, vomiting, and diarrhea cause an increase in fluid volume losses, in which case the patient will develop signs of dehydration such as pale, dry mucosal membranes, and sunken eyes. Because there is less fluid volume within the patient's vasculature, the blood pressure will also decrease as there is less fluid to exert force on the vessel walls with each heartbeat. The low blood pressure that results is known as hypotension. The heart will try to compensate for this hypotensive state by beating faster. This elevated heart rate is called tachycardia. These two symptoms, hypotension and tachycardia, do not create ideal conditions for sufficient oxygen perfusion throughout the body's vital tissues. There will be an increased metabolic demand for oxygen, thus the patient will breathe faster and their core temperature may increase. If the temperature increases, the patient may even begin to perspire (sweat), which further increases the fluid volume losses.

Because of the fluid volume deficit the patient has been experiencing, the nurse's priority should be obtaining fluids for the patient. If the dehydration issue is remedied, it is likely the vital signs will return to their expected ranges and the underlying cause of the prolonged nausea, vomiting, and diarrhea can be addressed.

The decision now lies between oral rehydration and IV fluid resuscitation. The patient is still complaining of nausea, vomiting, and diarrhea, which means there is no guarantee that increasing their oral intake of water will lead to absorption into the bloodstream. Rather, it is likely this fluid will return to the outside environment beforehand, either as vomitus or loose stool. With intravenous (IV) therapy, the fluid is delivered directly to the bloodstream, surpassing the need for absorption via the intestines.

Therefore, the nurse should prioritize requesting an order from the physician for IV rehydration therapy, option 3. Vital signs should be monitored frequently and a stool specimen may be obtained to address the underlying cause of the patient's present illness. However, the first thing that should be done is addressing the dehydration.