A client receives a prescription for dopamine 200 mg/500 mL IV to be infused over 45 minutes. The nurse should program the infusion pump to deliver how many mL/hr? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Rationale:

• Acute kidney injury: The client demonstrates markedly reduced urine output (oliguria), significant weight gain due to edema, and a history of hypovolemic shock with vasopressor support, all of which increase the risk for acute kidney injury. AKI can result from ischemic injury to the kidneys during shock and fluid shifts.

• Measure electrolyte levels: Electrolyte monitoring is essential in AKI, as kidney impairment can cause imbalances in potassium, sodium, and other ions. Detecting changes early prevents complications such as cardiac arrhythmias and neurologic disturbances. Electrolyte trends also guide fluid management and medication dosing.

• Assess lung sounds: Fluid retention from oliguria can lead to pulmonary edema. Assessing lung sounds helps identify crackles, wheezing, or other indications of fluid overload. Early detection allows timely interventions such as adjusting fluid administration or initiating diuretic therapy.

• Daily weight: Daily weight measurement is a reliable indicator of fluid retention or loss. The client’s rapid weight gain reflects edema and fluid accumulation, which correlates with worsening kidney function. Tracking weight trends informs the effectiveness of interventions and fluid management.

• Hemoglobin: Hemoglobin monitoring is important because anemia can occur from hemodilution, blood loss, or renal impairment. Decreased hemoglobin can worsen oxygen delivery to tissues and complicate recovery. Regular assessment ensures timely interventions like transfusions if needed.

• Hypovolemia: The client is demonstrating fluid overload rather than depletion, as evidenced by edema and weight gain. Hypovolemia is characterized by low blood pressure, tachycardia, and reduced perfusion, which are not present here.

• Hemorrhage: There is no active bleeding; the surgical site is intact with no drainage. Hemorrhage would present with hypotension, tachycardia, and signs of blood loss, which are absent.

• Septic shock: The client is afebrile, hemodynamically stable on this day, and without signs of infection. Although sepsis can cause oliguria, the current presentation is more consistent with post-shock AKI rather than systemic infection.

• Hold pressure on the surgical site: The surgical site is intact with no active bleeding, so applying pressure is unnecessary and would not affect AKI.

• Give 1,000 mL of isotonic solution IV: Excessive fluid administration could worsen edema and fluid overload in AKI. Careful fluid balance is required rather than liberal IV fluid boluses.

• Alert the rapid response team: The client is stable on the current assessment; there are no acute deterioration signs necessitating immediate rapid response activation.

• Capillary refill: While capillary refill assesses perfusion, this client’s perfusion is adequate. It is not a sensitive indicator for ongoing AKI or fluid overload.

• Surgical site drainage: There is no active drainage or bleeding; monitoring the site is routine but not a primary parameter for AKI.

• Electrocardiogram: ECG monitoring may be indicated for electrolyte disturbances, but daily monitoring is not the first-line parameter unless arrhythmias are suspected. Daily lab and clinical monitoring are more direct indicators.

Rationale:
A. Give a 0.9% normal saline bolus: Fluid resuscitation is a key component of sepsis management to support perfusion and blood pressure. However, initiating fluids does not take precedence over obtaining diagnostic cultures when the client is hemodynamically stable. Identifying the causative organism guides targeted therapy.

B. Collect specimens for blood cultures: Blood cultures must be obtained before initiating antibiotic therapy to accurately identify the infectious organism. A markedly elevated WBC count supports severe infection, and early culture collection improves diagnostic accuracy. This step is time-sensitive and directly impacts the effectiveness of subsequent antibiotic treatment.

C. Obtain blood for serum glucose: Serum glucose monitoring is important in sepsis due to stress-induced hyperglycemia. However, it does not influence immediate antimicrobial decision-making. This assessment can be performed after critical diagnostic specimens are collected.

D. Infuse first dose of antibiotics: Early antibiotics are essential in sepsis management, but administering them before obtaining blood cultures can compromise the ability to identify the pathogen. Best practice is to collect cultures first, then promptly start antimicrobial therapy.