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A client who is in shock is receiving a continuous IV infusion of a sympathomimetic dopamine. Which intervention should the nurse include in this client's plan of care?

A.

Obtain a blood pressure every 15 minutes.

B.

Monitor the client's complete blood count (CBC) daily.

C.

Review creatinine and blood urea nitrogen results.

D.

Measure the client's urinary output daily.

Answer and Explanation

The Correct Answer is A

Rationale:

 

A.Dopamine, a sympathomimetic agent, can cause significant changes in blood pressure. Monitoring blood pressure every 15 minutes is crucial to assess the client's response to the medication and to detect any adverse effects, such as hypertension or hypotension, promptly.

 


B.Monitoring CBC is important but not as immediately critical in this situation as monitoring blood pressure.

 


C.While reviewing creatinine and BUN results is important for overall kidney function, it is not the most immediate priority when administering dopamine for shock.

 


D. Measuring urinary output is important for assessing renal perfusion but should be done more frequently than daily in a client receiving dopamine for shock.


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View Related questions

Correct Answer is D

Explanation

Rationale:

A. Applying antibiotic ointment is not appropriate for this situation as the issue is likely compromised blood flow, not infection.

B. Checking oxygen saturation is not related to the color change of the stoma.

C. Switching to non-latex supplies is important for clients with latex allergies but is not relevant to the immediate problem.

D. A dark red to bluish color of the stoma suggests compromised blood flow and possible ischemia, which requires immediate medical attention. The nurse should notify the healthcare provider immediately to address this potentially serious complication.

Correct Answer is C

Explanation

Rationale:

A. Pneumonia typically presents with fever, productive cough, and lung consolidation, not just wheezing and low oxygen saturation.

B. Pneumothorax usually causes sudden sharp chest pain and decreased breath sounds on the affected side, rather than wheezing and prolonged expiration.

C. Asthma is characterized by wheezing, prolonged expiration, and low oxygen saturation due to bronchoconstriction and inflammation. The client's symptoms are consistent with an asthma exacerbation.

D. Bronchitis presents with a productive cough and sometimes wheezing but does not typically cause such severe hypoxemia or a pronounced increase in respiratory rate as seen here.

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