A client in septic shock has received 30 mL/kg of crystalloid fluid resuscitation but remains hypotensive with a MAP of 58 mm Hg. The provider orders norepinephrine (Levophed) infusion to be titrated to maintain MAP 265 mm Hg. Which nursing action is the HIGHEST priority when initiating this medication?
Verify the medication is infusing through a central venous catheter
Place the client on continuous cardiac monitoring
Assess baseline blood glucose level
Document the clients current level of consciousness
The Correct Answer is A
A. Norepinephrine is a potent vasoconstrictor, and if it infiltrates peripheral tissue, it can cause severe tissue necrosis and extravasation injury. Administering it through a central venous catheter is the highest priority safety measure when initiating the infusion to prevent serious complications.
B. Continuous cardiac monitoring is important because norepinephrine can cause tachycardia, arrhythmias, and increased myocardial oxygen demand, but the risk of tissue injury from peripheral administration is more immediately critical.
C. Assessing baseline blood glucose is not a priority for norepinephrine administration. Blood glucose monitoring may be relevant in critical care, but it does not directly prevent complications from norepinephrine infusion.
D. Documenting the client’s level of consciousness is important for ongoing assessment of perfusion and neurological status, but it is not the highest-priority action at the time of initiating a vasopressor infusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Retractions or depressions between ribs usually indicate increased work of breathing, but they are not specific for tension pneumothoraxand do not involve tracheal deviation or mediastinal shift.
B. Hyperresonance is typically percussed on the side with trapped air(the affected side), not the unaffected side. Hyperresonance alone does not confirm a tension pneumothorax.
C. Rales (crackles) are associated with fluid in the alveoli, such as in pneumonia or pulmonary edema. Tension pneumothorax involves air in the pleural space, not fluid, so rales are not expected.
D. In tension pneumothorax, air accumulates under pressure in the pleural space, compressing the lung and pushing the mediastinum, including the trachea, toward the unaffected side. This is a classic and life-threatening signthat requires immediate decompression.
Correct Answer is D
Explanation
A. The Rapid Shallow Breathing Index (RSBI) is calculated as the ratio of respiratory rate to tidal volume (in liters). An RSBI <105 is generally considered favorable for weaning. A value of 85 indicates the patient is breathing efficientlyand may be ready to wean.
B. Negative inspiratory force measures inspiratory muscle strength. Values more negative than -20 to -30 cm H2O are considered adequate. A NIF of -28 cm H2O indicates sufficient inspiratory strengthfor spontaneous breathing.
C. A tidal volume ≥5 mL/kg is generally acceptable for weaning. A value of 6 mL/kg indicates adequate ventilationduring spontaneous breathing trials.
D. A FiO2 >40% to maintain adequate oxygen saturation indicates ongoing oxygenation impairment, suggesting the client may not yet be ready for weaning. Successful weaning usually requires an FiO2 ≤40% and PEEP ≤5 cm H2O to maintain SpO2 ≥90–92%, ensuring the lungs can sustain oxygenation without excessive support.
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