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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Obtain a blood pressure reading before the client gets out of beD This intervention is important because the client is prescribed medications that may affect blood pressure, such as antidepressants and sedatives. Monitoring blood pressure before changes in position can help prevent orthostatic hypotension and related complications.

B. Measure and record the client's urinary output every day: While monitoring urinary output is important for overall assessment, it may not be the most immediate concern given the client's recent surgery and medication regimen.

C. Provide the client with teaching regarding a cardiac diet: While education on a cardiac diet is important for cardiovascular health, addressing immediate concerns related to medication effects and post-surgical recovery takes priority.

D. Obtain the client's vital signs every 4 hours when awake: While vital sign monitoring is essential, the timing of every 4 hours may not be necessary during sleep, and obtaining blood pressure readings before changes in position is more critical to prevent adverse events.

A. Place an indwelling urinary catheter and measure strict intake and output. B. Keep the bed in the lowest position and initiate seizure and fall precautions. C. Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. D. Maintain elevated positioning of the dependent joints on the affected side.

Correct Answer is C

Explanation

A. Placing an indwelling urinary catheter and measuring strict intake and output may be necessary for comprehensive assessment and management but is not the priority action in this situation, which suggests a possible stroke.

B. Keeping the bed in the lowest position and initiating seizure and fall precautions are important for safety, but the client's symptoms are suggestive of a stroke, and immediate evaluation and potential treatment are needed.

C. Starting two large-bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is the priority action. The client's symptoms, including right-sided weakness and sluggish speech, suggest a potential ischemic stroke. IV fibrinolytic therapy (e.g., tissue plasminogen activator) is time-sensitive and may be indicated for eligible patients with acute ischemic stroke.

D. Maintaining elevated positioning of the dependent joints on the affected side is not the priority action in this situation. Immediate assessment and potential treatment for a suspected stroke are needed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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