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.

Answer and Explanation

The Correct Answer is C

Choice A reason: Assessing pupillary response to light hourly is not related to dopamine administration. Dopamine does not affect the pupils or the cranial nerves that control them.

Choice B reason: Initiating seizure precautions is not necessary for a client receiving dopamine. Dopamine does not lower the seizure threshold or cause convulsions.

Choice C reason: Measuring urinary output every hour is an important intervention for a client receiving dopamine. Dopamine increases blood pressure and cardiac output, which improves renal perfusion and urine production. Urinary output is an indicator of the effectiveness of dopamine therapy and renal function.

Choice D reason: Monitoring serum potassium frequently is not directly related to dopamine administration. Dopamine does not affect potassium levels or cause hyperkalemia or hypokalemia. However, potassium levels may be affected by other factors such as fluid balance, renal function, and medications.

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Correct Answer is D

Explanation

Choice A reason: Securing chest tube to the stretcher for transport is not the most important action for the nurse to take. Chest tube is a device that drains air or fluid from the pleural space or mediastinum after surgery or trauma. Securing chest tube to the stretcher can prevent accidental dislodgement or kinking of the tube during transport, but it is not as crucial as maintaining proper drainage.

Choice B reason: Administering PRN pain medication prior to transport is not the most important action for the nurse to take. Pain medication is a drug that relieves pain by blocking pain signals or reducing inflammation. Administering pain medication prior to transport can improve comfort and reduce anxiety for the client, but it is not as urgent as preventing complications.

Choice C reason: Marking the amount of chest drainage on the container is not the most important action for the nurse to take. Chest drainage is the fluid or air that collects in the chest tube container after being drained from the pleural space or mediastinum. Marking the amount of chest drainage on the container can help monitor fluid balance and detect excessive bleeding or leakage, but it is not as vital as ensuring proper drainage.

Choice D reason: This is the correct answer because keeping chest tube container below the site of insertion is the most important action for the nurse to take. Chest tube container is a device that collects air or fluid from the chest tube and maintains negative pressure in the pleural space or mediastinum. Keeping chest tube container below the site of insertion can prevent backflow of air or fluid into the chest cavity and maintain adequate drainage. If the chest tube container is raised above the site of insertion, it can cause tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and compresses the lung and heart.

A. Apply the client's positive airway pressure device. B. Elevate the head of the bed to a 45 degree angle. C. Remove dentures or other oral appliances. D. Lift and lock the side rails in place.

Correct Answer is A

Explanation

Choice A reason: applying the client's positive airway pressure device can help prevent or reduce episodes of apnea and hypopnea during sleep by keeping the airway open and delivering oxygen. The nurse should ensure that the device fits properly and that the client knows how to use it.

Choice B reason: elevating the head of the bed to a 45 degree angle is not as effective as using a positive airway pressure device for a client with OSA. Elevating the head of the bed may help reduce snoring and improve breathing, but it may not prevent airway collapse or oxygen desaturation.

Choice C reason: removing dentures or other oral appliances is not as important as applying a positive airway pressure device for a client with OSA. Removing dentures or other oral appliances may help prevent choking or aspiration, but it may not prevent airway collapse or oxygen desaturation.

Choice D reason: lifting and locking the side rails in place is not as important as applying a positive airway pressure device for a client with OSA. Lifting and locking the side rails in place may help prevent falls or injuries, but it may not prevent airway collapse or oxygen desaturation.

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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?

Nursing Test Bank

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Explanation

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