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A nurse is caring for a client in the ICU

Exhibits

For each potential nursing action, click to specify if the action is essential, nonessential, or contraindicated for the client.

A.

Administer furosemide

B.

Administer ordered Epinephrine drip

C.

Administer ordered low dose dopamine

D.

Insert an indwelling urinary catheter.

E.

Administer ordered nitroglycerin

F.

Administed 0.9% NS 500ML bolus

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

  • Administer furosemide: The patient has signs of pulmonary edema which needs to be managed.
  • Administer ordered Epinephrine drip: Epinephrine is crucial for managing hemodynamic instability.
  • Insert an indwelling urinary catheter: Monitoring urine output helps assess kidney function and fluid balance.
  • Administer ordered low dose dopamine: Useful for maintaining renal perfusion and blood pressure.
  • Administered 0.9% NS 500 mL bolus: Helps address hypotension and volume deficit.
  • Administer ordered nitroglycerin: Not needed in this acute post-arrest phase unless specifically indicated for managing ongoing angina or heart failure symptoms.


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Related Questions

Correct Answer is ["B","C","D","E"]

Explanation

A. Ecchymosis indicates bruising but is not a primary parameter for assessing neurovascular status.

B. Skin integrity is important to monitor for any signs of breakdown or infection.

C. Temperature helps assess for adequate blood flow and potential complications.

D. Color of the extremity indicates blood flow and can show signs of compromised circulation.

E. Sensation checks for nerve damage or impaired circulation.

Correct Answer is ["B","C","E"]

Explanation

A. Increase in hematocrit is not expected in fluid overload; it generally decreases due to dilution of blood components.

B. Increased respiratory rate can occur as the body tries to compensate for fluid overload, which may affect lung function and cause respiratory distress.

C. Increased blood pressure is a common finding in fluid overload due to increased blood volume in the circulatory system.

D. Increased temperature is not a typical finding in fluid overload; it might be associated with infection or inflammation instead.

E. Increased heart rate can occur as the body compensates for increased blood volume and higher blood pressure.

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