A patient who has neurogenic shock is receiving a dobutamine infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action?

The patient's IV infusion site is cool and pale.

The patient's extremities are warm and dry.

The patient's urine output is 28 ml, over the past hour.

The patient's heart rate is 58 beats/min.

Answer and Explanation

The Correct Answer is A

A. In a patient receiving a dobutamine infusion, which is a vasopressor medication used to increase cardiac output, a cool and pale IV infusion site could indicate inadequate perfusion despite treatment. This finding requires immediate action to assess the patient's hemodynamic status and ensure adequate tissue perfusion.

B. Warm and dry extremities are typically indicative of adequate tissue perfusion. In neurogenic shock, vasodilation can lead to warm extremities due to decreased systemic vascular resistance. While this finding may be expected in neurogenic shock, it does not necessarily indicate a need for immediate action if other parameters are stable.

C. Decreased urine output can be indicative of inadequate renal perfusion and impaired kidney function. In a patient with neurogenic shock, maintaining adequate renal perfusion is crucial to prevent acute kidney injury. While decreased urine output warrants close monitoring and intervention, it may not require immediate action unless other signs of worsening perfusion are present.

D. A heart rate of 58 beats/min may be within the normal range for some patients, especially those who are receiving dobutamine, which can have a chronotropic effect. However, in the context of neurogenic shock, bradycardia may indicate a compensatory response to hypotension and decreased tissue perfusion. While bradycardia alone may not always require immediate action, it should prompt further assessment of the patient's hemodynamic status and response to treatment.

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Correct Answer is A

Explanation

A In atrial fibrillation (AF), the electrical activity in the atria is chaotic, leading to an irregularly irregular ventricular response. As a result, the pulse felt at the radial artery will be irregular, with no discernible pattern. The irregularity is a hallmark feature of AF and is often described as "irregularly irregular."

B Bounding pulses are characterized by a strong and forceful pulsation felt at the arterial pulse sites. In atrial fibrillation, the irregular and rapid ventricular response can lead to an increased stroke volume and forceful contraction of the left ventricle during diastole, resulting in bounding pulses. However, bounding pulses are not typically associated with atrial fibrillation; they are more commonly seen in conditions such as aortic regurgitation or hyperdynamic circulation.

C In some cases of atrial fibrillation, especially if the ventricular rate is very rapid or irregularly irregular, the pulse may not be palpable due to the inconsistent ventricular contractions.

However, in most cases of atrial fibrillation, a pulse is palpable, albeit irregular.

D Atrial fibrillation can result in a rapid ventricular response, leading to a fast heart rate. However, the pulse rate can vary widely among individuals with atrial fibrillation. While some may have a rapid heart rate (tachycardia), others may have a slower heart rate (bradycardia), depending on factors such as concomitant medications, autonomic tone, and the presence of underlying heart disease.

A. Apneustic respirations B. Cheyne-Stokes respirations C. Stridor D. Kussmaul respirations

Correct Answer is B

Explanation

B. Cheyne-Stokes respirations involve a cyclical pattern of breathing characterized by gradual increase and decrease in the depth and rate of respirations, with periods of hyperventilation alternating with periods of apnea. It is commonly seen in patients with neurological disorders, heart failure, or drug overdose.

A. Apneustic respirations are characterized by prolonged inspiratory gasps followed by a brief pause and insufficient expiration. This pattern is often associated with damage to the pons in the brainstem.

C. Stridor is a high-pitched, noisy respiratory sound caused by turbulent airflow through partially obstructed airways. It is typically heard during inspiration and is often associated with upper airway obstruction, such as in cases of croup or epiglottitis.

D. Kussmaul respirations are deep, rapid, and labored breathing patterns often seen in patients with metabolic acidosis, particularly diabetic ketoacidosis. Unlike Cheyne-Stokes respirations, Kussmaul respirations do not involve periods of apnea.

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A patient who has neurogenic shock is receiving a dobutamine infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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