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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 A

Explanation

A. Yellow sclera
Yellow sclera indicates jaundice, which could be a sign of liver dysfunction. Both isoniazid and rifampin can cause hepatotoxicity, and monitoring for jaundice is crucial to ensure the safety of the client.

B. Increasing AST level
AST level is slightly elevated but remains in the upper range of normal. Continued monitoring is necessary but may not require immediate reporting unless liver function significantly deteriorates.

C. Weight loss
Weight loss is consistent with the client’s condition and does not necessarily require immediate reporting unless it is severe or unmanageable.

D. Mantoux test result
The Mantoux test result is negative, which may be expected in the early phase of tuberculosis treatment. It should be monitored over time.

E. Increasing ALT level
ALT is slightly elevated but still within normal limits, though it's essential to continue monitoring for trends.

F. Reddish-orange urine color
Reddish-orange urine is a known side effect of rifampin and does not typically require immediate reporting

Correct Answer is ["125"]

Explanation

To calculate the IV pump rate:

- Total volume of dextrose solution: 250 mL

- Time for infusion: 2 hours

- The pump rate is calculated as total volume divided by time: 250/2

- This results in a pump rate of 125 mL/hr

Therefore, the nurse should set the IV pump to deliver 125 mL/hr.

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