A nurse is monitoring a client who is receiving a continuous IV infusion of dopamine. Which of the following findings requires immediate intervention by the nurse?
Heart rate 105/min
Infiltration of the peripheral IV
Increased blood pressure
Occasional premature ventricular complexes (PVCs)
The Correct Answer is B
Rationale:
A. A heart rate of 105/min is slightly elevated, but it does not require immediate intervention unless the client is symptomatic or has other concerning signs.
B. Infiltration of the peripheral IV requires immediate intervention, as it can lead to tissue damage and prevent the medication from being effectively delivered. The nurse should stop the infusion, assess the site, and take appropriate action.
C. Increased blood pressure is a common effect of dopamine administration and does not necessarily require urgent intervention unless it becomes critically high or is associated with other adverse symptoms.
D. Occasional PVCs can occur during dopamine infusion and can be monitored unless they become frequent or symptomatic; they typically do not require immediate intervention.
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Correct Answer is A, B, C, D, E
Explanation
Rationale:
- Administering albuterol first is crucial because it is a bronchodilator that will help open the airways before administering the anti-inflammatory fluticasone.
- The client should rest for 1 minute between puffs of albuterol to allow for the medication to take effect.
- After taking the second puff of albuterol, a longer rest of 5 minutes allows the client to experience the full effects of the bronchodilator.
- Finally, administering fluticasone afterward will help reduce inflammation in the airways, maximizing the benefit of both medications.
Correct Answer is A
Explanation
Rationale:
A. Increase calcium intake: Leuprolide can cause a decrease in bone density, increasing the risk of osteoporosis. Therefore, the nurse should advise the client to increase calcium and vitamin D intake to help maintain bone health.
B. Keep the solution cold for administration: Leuprolide should be stored at room temperature, not refrigerated, for subcutaneous administration.
C. This medication can cause low blood glucose levels: Leuprolide does not typically affect blood glucose levels. However, it can cause other endocrine-related side effects, such as hot flashes and reduced libido.
D. This medication can cause constipation: Constipation is not a common side effect of leuprolide. Instead, leuprolide is more likely to cause side effects such as hot flashes and loss of bone density.