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 C
Explanation
Rationale:
A. Applying a warming blanket is not appropriate, as it may exacerbate the client's reaction to the infusion and is not a standard pre-medication strategy.
B. Infusing amphotericin B deoxycholate over 1 hour is too rapid; it is typically infused over 2-6 hours to minimize adverse effects.
C. Administering diphenhydramine prior to the administration of amphotericin B can help prevent or alleviate infusion-related reactions such as fever and chills, which the client experienced during previous infusions.
D. Monitoring vital signs once per hour following administration is insufficient; vital signs should be monitored more frequently during and immediately after the infusion to promptly detect and address any adverse reactions.
Correct Answer is D
Explanation
Rationale:
A. This statement is incorrect because the client should remove contact lenses before administering brimonidine and wait at least 15 minutes before reinserting them to ensure proper absorption and avoid irritation.
B. While some mild irritation can occur, it is not a desired effect and should not be expected; the nurse should clarify what level of irritation is considered normal.
C. This statement is incorrect as brimonidine is typically a long-term treatment for glaucoma, and clients should not stop using it without consulting their provider.
D. This statement is correct; brimonidine can cause changes in eye color, particularly in individuals with lighter colored eyes, and the client should be informed about this possibility.