A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion.
Which of the following actions should the nurse plan to take?
Keep calcium gluconate at the client's bedside.
Attach an inline filter to the IV tubing.
Protect the IV bag from exposure to light.
Monitor blood pressure every 2 hr.
The Correct Answer is C
Answer is: c. Protect the IV bag from exposure to light.
Explanation: Nitroprusside degrades when exposed to light, so the nurse should protect the IV bag from light exposure to maintain the medication's potency and effectiveness in treating the client's severe hypertension.
Choice a. is wrong because calcium gluconate is used as an antidote for magnesium sulfate toxicity. Although it may be kept on hand in some facilities, it is not directly related to the administration of nitroprusside.
Choice b. is wrong because attaching an inline filter is not necessary when administering nitroprusside. It is more relevant for medications that require filtration, such as certain chemotherapeutic agents.
Choice d. is wrong because monitoring blood pressure every 2 hours is not frequent enough for a client receiving nitroprusside. The nurse should monitor the client's blood pressure more frequently, such as every 5 to 15 minutes, depending on facility policies and the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
No explanation
Correct Answer is D
Explanation
Choice A rationale:
Diazepam (Valium) is not the correct choice in this situation. Diazepam is a sedative and muscle relaxant but would not address the respiratory depression caused by hydromorphone. The client's respiratory rate of 10/min indicates a potential opioid overdose, and the appropriate intervention is to administer naloxone to reverse the opioid effects.
Choice B rationale:
Acetaminophen (Tylenol) is not the correct choice in this scenario. Acetaminophen is a pain reliever and fever reducer but would not address the respiratory depression caused by hydromorphone. The priority is to address the respiratory depression promptly with naloxone.
Choice C rationale:
Ibuprofen (Advil) is not the correct choice in this situation. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation but is not appropriate for reversing opioid-induced respiratory depression. Naloxone is the drug of choice to reverse opioid overdose in this case.
Choice D rationale:
Naloxone (Narcan) is the correct choice. Naloxone is an opioid receptor antagonist used to reverse the effects of opioid overdose, including respiratory depression. Given the client's low respiratory rate, naloxone should be administered promptly to counteract the effects of hydromorphone. This is the most appropriate and potentially life-saving intervention for this client.
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