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. Furosemide is a diuretic that promotes urine production but is not indicated for treating bladder distention or urinary retention post-surgery.
B. Lorazepam is an anxiolytic medication and does not address urinary retention or bladder distention.
C. Bethanechol is a cholinergic agent that stimulates bladder contraction and is used to treat urinary retention. It helps to facilitate voiding in clients who have difficulty.
D. Atropine is an anticholinergic medication that can actually inhibit bladder contraction, making it inappropriate for this situation.
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.