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?
Obtain a blood pressure every 15 minutes.
Monitor the client's complete blood count (CBC) daily.
Review creatinine and blood urea nitrogen results.
Measure the client's urinary output daily.
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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Correct Answer is B
Explanation
Rationale:
A. A cheerful and calm appearance may not always align with the client's emotional needs and could feel insincere.
B. As the client nears the end of life, their hopes may shift, and it is crucial for the spouse to listen and help fulfill these evolving goals to provide comfort and maintain dignity.
C. Encouraging the client to make decisions as they are able can empower them, rather than avoiding decision-making.
D. Offering favorite foods is thoughtful but does not directly address the emotional and psychological aspects of hopelessness.
Correct Answer is D
Explanation
Rationale:
A. Lubricating lotion may be helpful for dry skin but is not necessary for these lesions.
B. A biopsy is not typically required for benign lesions such as senile lentigines, unless there is suspicion of malignancy.
C. Recent international travel is unrelated to the development of senile lentigines.
D. Senile lentigines, also known as "liver spots" or "age spots," are common in older adults. They are benign lesions that result from sun exposure and aging. Recording their presence is appropriate for documentation, as they are generally not harmful.