A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 6 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

Choice A reason: A 16-year-old client diagnosed with major depression who refuses to participate in group does not require the nurse's immediate attention. Depression is a mood disorder that causes persistent feelings of sadness, hopelessness, and loss of interest. Refusing to participate in group may indicate low motivation, social withdrawal, or poor self-esteem, which are common symptoms of depression. The nurse should respect the client's preference and offer alternative activities or individual therapy.

Choice B reason:This client requires immediate intervention because pacing can be a sign of agitation, restlessness, or escalating mania. Clients with bipolar disorder in a manic phase may exhibit increased energy, impulsivity, irritability, and even aggression. If not addressed promptly, this behavior could escalate to disruptive outbursts, impulsive actions, or even violence toward themselves or others. The nurse should intervene by using calm communication, redirection, and possibly medication if prescribed to help de-escalate the situation and ensure safety.

Choice Creason:This scenario involves peer conflict, which is important to address, but it does not necessarily indicate an immediate risk of harm. Clients with antisocial behavior often engage in conflict due to manipulative or confrontational tendencies, but being yelled at does not mean they are in immediate danger. The nurse should monitor the situation and intervene to prevent escalation, but other safety concerns take priority.

Choice D reason: A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack does not require the nurse's immediate attention. Anorexia nervosa is an eating disorder that causes extreme restriction of food intake and fear of weight gain. Refusing to eat the evening snack may indicate distorted body image, dietary rules, or anxiety, which are common factors of anorexia nervosa. The nurse should encourage the client to eat and provide support and education.

A. Secure chest tube to the stretcher for transport: While securing the chest tube is important to prevent dislodgement during transport, the priority is to ensure proper drainage and prevent air leaks by keeping the chest tube container below the site of insertion.
B. Mark the amount of chest drainage on the container: While it's important to document chest drainage, ensuring proper drainage by keeping the container below the insertion site takes precedence, especially during transport.
C. Keep the chest tube container below the site of insertion: Correct! Keeping the chest tube
container below the site of insertion ensures continuous drainage of air and fluid from the pleural space, which is crucial for maintaining respiratory function and preventing complications such as pneumothorax.
D. Administer PRN pain medication prior to transport: Pain management is important, but in this urgent situation, maintaining proper chest tube function and respiratory support is the priority.