A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?
Assess pupillary response to light hourly.
Initiate seizure precautions.
Monitor serum potassium frequently.
Measure urinary output every hour.
The Correct Answer is D
A. Assess pupillary response to light hourly: Dopamine administration may cause changes in pupillary response, but it is not the primary concern associated with its administration. Hourly pupillary assessment may not be necessary unless other signs of neurological changes are present.
B. Initiate seizure precautions: While dopamine administration may cause neurological effects, such as agitation or tremors, it is not typically associated with seizure activity. Seizure precautions are not indicated solely due to dopamine infusion.
C. Monitor serum potassium frequently: Dopamine administration can affect potassium levels, but monitoring serum potassium levels frequently may not be necessary unless the client has pre- existing potassium imbalances or is at risk for electrolyte disturbances.
D. Measure urinary output every hour: Dopamine is a vasopressor medication that can increase blood pressure and cardiac output, potentially leading to increased renal perfusion and urinary output. Monitoring urinary output hourly is essential to assess the client's response to dopamine therapy and ensure adequate renal function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Encouraging the nurse to flush the tube with more water is not mentioned as a necessary action based on the information provided. Flushing with water is typically done to ensure the tube
remains patent and to prevent medication interactions within the tube, but the scenario does not indicate that the nurse failed to do this or that there was an issue with tube patency.
B. Instructing the nurse to administer each medication separately is correct. This is important to prevent drug interactions within the tube and to ensure accurate dosing. Administering
medications separately allows for proper absorption and can prevent complications such as clogging of the tube.
C. Adding the liquid volumes when documenting fluid intake is correct. It is essential to account for all sources of fluid intake to maintain accurate fluid balance records. Medications
administered through a gastrostomy tube contribute to the patient's overall fluid intake and must be included in the documentation.
D. Confirming that the nurse determined the amount of gastric residual is correct. This is a critical step to ensure that the patient is tolerating the feedings and to prevent complications such as
aspiration. Gastric residual volume can indicate if the patient's digestive system is processing the feeding appropriately.
E. Advising the nurse to use the plunger when giving medications is not necessary in this context. The use of a plunger can be appropriate in some situations, but the scenario does not provide enough information to suggest that the nurse had difficulty administering the medications that would require the use of a plunger. Additionally, using a plunger can increase the risk of tube
damage or patient discomfort.
Correct Answer is C
Explanation
A. Providing pain medication to increase the client's tolerance of labor pains: Pain management is important throughout labor, but in the second stage, the focus shifts to pushing efforts and fetal expulsion. Pain medication may affect the client's ability to push effectively and may not be
indicated at this stage.
B. Assessing the fetal heart rate and pattern for signs of fetal distress: Fetal monitoring is essential throughout labor, including the second stage, to assess fetal well-being and detect signs of
distress. However, the specific intervention indicated for the second stage is assisting the client with pushing.
C. Assisting the client to push effectively so that expulsion of the fetus can be achieveD Correct!
In the second stage of labor, the cervix is fully dilated, and the focus is on pushing efforts to
facilitate the birth of the baby. The nurse plays a crucial role in supporting the client during this stage by providing guidance on effective pushing techniques and encouragement.
D. Monitoring effects of oxytocin administration to help achieve cervical dilation: Oxytocin administration is typically used in the first stage of labor to induce or augment contractions and facilitate cervical dilation. Monitoring its effects is important, but it is not a specific intervention for the second stage of labor, where the focus is on pushing and fetal expulsion.
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