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.
Measure urinary output every hour.
Monitor serum potassium frequently.
The Correct Answer is C
A. Assessing pupillary response to light is not directly related to the administration of dopamine for hypotension and does not reflect the immediate effects of the medication on the cardiovascular or renal systems.
B. Seizure precautions are not a standard intervention for a patient receiving dopamine unless the patient has a history of seizures or there is another indication for such precautions.
C. Measuring urinary output every hour is essential as it reflects the patient's fluid balance and kidney function, which can be affected by dopamine administration. It is a direct measure of the effectiveness of the medication in improving renal perfusion and the patient's hemodynamic status.
D. While monitoring serum potassium levels is important in patients receiving IV therapy, it is not the most immediate concern when administering dopamine for hypotension, unless the patient has a known electrolyte imbalance.
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Related Questions
Correct Answer is C
Explanation
A. When the client has ankle edema Ankle edema may indicate fluid retention, which is common during pregnancy but is not directly related to the assessment of deep tendon reflexes (DTRs).
B. Within the first trimester of pregnancy: Assessing DTRs within the first trimester of pregnancy is not specifically indicated unless there are other signs or symptoms of concern.
C. If the client has an elevated blood pressure: Assessment of DTRs is particularly important if the client has an elevated blood pressure, as it may indicate preeclampsia, a serious pregnancy complication characterized by hypertension and proteinuria.
D. During admission to labor and delivery: While assessment of DTRs may be included in the admission assessment to labor and delivery, it is particularly important to assess DTRs if the client has an elevated blood pressure, as it may indicate preeclampsia.
Correct Answer is C
Explanation
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.
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